The early treatment of war wounds

THE

EARLY TREATMENT
OF WAR WOUNDS

H.M.W GRAY

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K . P. 24

THE

EARLY TREATMENT
OF WAR WOUNDS

. ^

COLONEL Hf Nf. W. GRAY

C.B., C.M.G., M.B. Aberdeen, F.R.C.S. Ed.

Consultant in Special Military Surgery, late Consultant Surgeon,
British Expeditionary Force, France

LONDON

HENRY FROWDE HODDER & STOUGHTON

Oxford University Press Warwick Square,

1919

foreword

13y Lt. -General T. H. J. C. Goodwin, C.B., C.M.G.,
etc., Director-General of Army Medical Service

The experience of our military authorities in the
present war has been that, for long periods, it was
not possible to carry out any “ war of movement.
Our armies were obliged — though not content o
hold their own against greatly superior odds.

As regards Military Surgery during the first two
years of the war we were encountering unfamiliar
conditions, acquiring new experiences, and dealing
with wounds of a nature, and on a scale, hitherto

undreamed of. , , , .

It was perhaps inevitable that advances should at

first be somewhat slow. During the last year or two
allairs appear to have progressed more rapidly and
satisfactorily, and great improvements have lx:en made
in many directions. The early treatment of wounds,
the prevention and treatment of shock and collapse,
the operative procedures in all types of injury, and
many other problems, have received close attention
with the result that the advance in these and many
other matters has been very marked.

Thousands of limbs and lives are now saved which,
at the commencement of the war, would have been
regarded as irretrievably lost.

vtt

/

VI 11

FOREWORD

Our views on many questions and problems have
changed, arc still changing, and no doubt will become
still further advanced in the future. It is very
important that the present situation as regards
advances in Military Surgery should be clearly and
definitely set forward and published in concise form,
in order that every surgeon throughout our various
areas of war may become fully acquainted with the
methods at present in vogue.

Under the conditions of life which now obtain, the
Army surgeon has not such full opportunities for
study as might be desired, and this small handbook
by Colonel Gray, giving the valuable experiences of
himself and other workers, should prove of immense
assistance.

T* H. Goodwin, D.G

September 9th r 1918.

PREFACE

Fob three and a half years I served as Consultant
Surgeon in France. The first eighteen months were
spent at the Base, the last two years with one of
the Armies. The D.M.S. of that Army placed upon
me the responsibility of ensuring “ that the standard
of surgical work in the Army should be as high as
possible.”

This book is a record of what was done by the
surgical workers of that Army and a testimony to
the efficiency of the administrators who facilitated
that work. In it I have attempted to convey to
medical men who have not yet had the good fortune
to have been selected for duty at the Front either in
France or elsewhere, some idea of the nature of the
work to be done there and of the aspirations of the
men who have tried to “ make good ' 1 in carrying
out that work.

It is hoped, also, that the book will be of assistance
to those surgeons who, having had no experience of
the early treatment of war wounds, may be called
upon, possibly with little warning, to treat such
wounds soon after their infliction.

There is little time in these busy days for reading
long dissertations. Volumes have been written on

ix

/

X

PREFACE

the subject matter of almost every one of the chapters
of this book, and more especially of those dealing
with regional injuries, but. it is believed that the
brevity here displayed in treating these subjects will
not diminish materially the usefulness of the book.

It can hardly be expected that all the recommenda-
tions made will pass unchallenged, but as they are
the outcome of concentrated observation and thought
by one who has had unusual opportunities, and of
discussion and collaboration with numerous brilliant
young surgeons possessed of fresh, active brains and
equally dexterous hands, they ought to possess a
value of their own. Most of the procedures adopted
received general recognition and application, in some
instances, however, only after considerable delay,
which, in view of the clamant need for rapid develop-
ments, seemed to me regrettable-

This is a young man’s war, in surgery as well as
in purely military matters. The progress of events
demands that younger men should have every chance
in a sphere of action where mental and bodily activity
count for so much.

The Third Army was professionally happy so far as
the exigencies and limitations of war would allow.
It was an Army where one man shared his knowledge
with another, where collaboration and loyalty were
combined, to the great benefit of the wounded man.
The happiness, efficiency, and enterprise in that Army
were due in very large measure to the Sahib at the
head of its Medical Service, Sir J. Murray Irwin,
K.C.H.G , C R

It was a great privilege and honour to work with

PREFACE

xi

the medical officers of that Army. Their keenness
and efficiency were inspiring, and their thoughtfulness
and courtesy afforded a constant encouragement.
Amongst them are many who did most excellent
work in an unobtrusive way ; though their qualities
have not yet received adequate recognition, they are
bound to make their mark. It would be invidious
to name them here. To one and all I feel most
grateful.

I am sure that no one will take umbrage when I
make an exception and mention the name of Captain
K. M. Walker, whose w'ork in the forward areas has
been of such a pioneer kind, so good, so unassuming,
and so helpful to wounded men and to medical offi-
cers alike. He compiled, along with me, the small
pamphlet on the work of advanced units, which was
circulated in our Army and which is embodied m
the first chapter of this book. He is mainly respon-
sible for the chapter on Wound Shock.

All will unite with me in unstinted praise of the
Nursing Sisters, who contribute so much to the
success of the surgeons’ work. Their untiring devo-
tion to duty, in spite of frequent discomfort and
danger, is a never-ending wonder. The orderlies,
stretcher-bearers, and ambulance car drivers also can-
not be forgotten. Among the theatre and ward
orderlies are assistants as faithful, capable and willing
as one could wish to have. The stretcher-bearer on
the field is one of the heroic figures of the war.

Many of the chapters on operative work were
written in their original form for a pamphlet on
surgical treatment of war wounds which was circu-

xti

PREFACE

la ted in the Third Army in the beginning of 1917.
They were drawn up in collaboration with the surgical
specialists of the casualty clearing stations in that
Army. For this reason I have drawn to a consider-
able extent, in the chapters on general wound treat-
ment and on treatment of fracture of the femur,
from the contributions to that pamphlet by Major
C, II. Upcott and Lt.-Col. R. C, Dun. The chapters
on head and knee injuries were largely written at
the Base in 1915. Most of the chapters, in a some-
what different form, have been published in the New
York Medical Journal.

I have not written anything on abdominal wounds.
It has always seemed to me that a surgeon who has
mastered the technique of successful excision of an
ulcerating cancer of the colon is capable of obtaining
as good results as possible if he applies the same
principles in the treatment of war wounds of the
abdominal organs coupled with those used in com-
batting spreading peritonitis* To Major-General C. S.
Wallace, C.B., is chiefly due the credit of haying
rescued such wounds from the application of the
policy of noli me iangere . I recommend the paper by
Colonel Owen Richards, D.S.O., published in the
British Medical Journal , April 27th, 1918, on “ The
Selection of Abdominal Cases for Operation,” to the
attention of abdominal operators.

I have dealt only incidentally with the organisation
ol surgical work, and of the special arrangements
which must be made before and during active fighting,
these matters were the subject of numerous memor-
anda drawn up in my capacity of Consultant Surgeon

PREFACE

xiu

with the Third Army* They were circulated officially
from time to time in that Army, and will, I hope,
prove to have some permanent Value*

Medical officers who have not experienced the stress,
anxiety, and limitations of work near the Front
during severe fighting must read this book with open
minds and sympathetic tolerance. The conditions of
patients 5 wounds as well as their hold on life vary
so enormously within short spaces of time that a
man who has been literally snatched from death at
a dressing station or casualty clearing station may
seem to have but little wrong with him when he is
safely tucked in bed in a Rase hospital. Needless to
say, the reverse side of the picture is only too fre-
quently seen. Surgeons in advanced units can, even
in quiet times, only approach the ideal which it is
possible to attain in more permanent surroundings.
It is essential to take a broad-minded view, and never
to forget that there are more ways than one of
applying the same principle. The particular method
adopted by a medical officer at the Front in any
given case must be determined by the conditions on
the spot, the facilities at hand, the number of cases
that come in, and the circumstances affecting evacua-
tion. If the correct principle has been recognized
and applied, to criticize the means because they do
not conform to some particular technique would be
to take a narrow view*

II. M. W. GRAY.

August t9LS.

CONTENTS

CHAPTER I

PAGE

Surgical Treatment of Wounded Men at

Advanced Units ..... 1

CHAPTER II

Work at a Casualty Clearing Station . 68

CHAPTER III

The Treatment of Wound Shock . . 80

%

CHAPTER IV

Considerations regarding the Use of Dif-
ferent Kinds of Antiseptics and Dress-
ings

CHAPTER V

Principles of Treatment of Gunshot

Wounds at Casualty Clearing Stations 123

XX v

CONTENTS

xv

CHAPTER VI

Operative Treatment of War Wounds

CHAPTER VII

Wounds of the Brain and its Coverings .

CHAPTER VIII

Penetrating Wounds of the Thorax

CHAPTER IX

Injuries of the Spinal Cord . *

CHAPTER X

Compound Fracture of the Femur .

CHAPTER XI

Wounds of Joints .

Postscript '

Author’s Publications on War Work

Index

PAGE

143

174

213

230

288

254

275

276

277

THE

)

EARLY TREATMENT
OF WAR WOUNDS

CHAPTER I

SURGICAL TREATMENT OF WOUNDED MEN AT
ADVANCED UNITS

It is beyond the power of words to convey any-
thing but the feeblest impression of the conditions
under which surgical work is carried on at a very
advanced unit during a big “ push.” For the doctor
fresh from a palatial, well-ordered hospital, who
has hitherto had all things made easy in virtue of
his training and surroundings, and who may be so
confident of obtaining good results that he dreams
of performing marvellous operations at the front,
there will be much to learn and much to unlearn.
The dimly lighted dugout dressing - station, the
dust, the wet, the mud, the blood, the noise, the
bustle, the numbers of wounded, the appalling
wounds, the hopeless shock — -will open his eyes, test
his capacity and resource, and tend to break his
heart as never before. Here is no brilliantly lighted
and fully equipped theatre, here his patients do not
1

83418

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2 EARLY TREATMENT OF WAR WOUNDS

come before him in spotless apparel, here he has not
unlimited skilled assistance, here no aseptic ritual is
possible, here he must be content with very simple
things. And through it all he must keep cool, he
must hurry, he must be thorough, he must be gentle
and careful in every possible way. His is the re-
sponsibility to make or mar a man for life. Often
his patients, shattered in nerve as well as in limb,
can give but feeble response to his utmost efforts,
so that a little slip in judgment, a little unnecessary
exposure, a little lack of ordinary comfort even, or a
little rough or unconsidered handling will tip the
scale and send them to that death which their foes
have desired.

What a necessity for each equipping himself as
best he can so that he may give of his best to
those who deserve it more than ever men did ! In
so far as we fail to accommodate ourselves to these
unavoidable conditions or neglect opportunities of
acquiring for ourselves or imparting to others the
special knowledge which will help our wounded men,
and fail to put that knowledge into practice, so far
do we fail in duty to our country. These chapters
set forth what the writer after a varied experience
of nearly four years has found to be the best
methods of treatment for the wounded man from
a purely professional point of view. Administration
is not dealt with, although any attempt to divorce
administrative from professional work is full of
danger to the success of our calling. If the ad-
ministrator neglects the advice of his clinical brother
his administration may result, during a big battle, in

WOUNDED MEN AT ADVANCED UNITS

the loss of literally hundreds of lives and of limbs
which would otherwise have been saved.

It is impossible to enter into details with regard to
all procedures or types of injury. Some are described
more fully than others for various reasons. One is
impressed by the fact that the methods of treatment
which are most successful are those which are simplest
and follow the indications of Nature most closely.
The medical officer who can land his patient at the
next stage of the journey in best condition with the
fewest contraptions serves his country best. Some
measures described are so simple that, were they not
so frequently neglected, it would appear almost
superfluous to draw special attention to them.
Principles of surgery remain the same, but the
application of them is perforce adapted to local con-
ditions: Original minds will always devise the means

to the end in the greatly varying and new conditions
which this war will continue to force upon them.
At the field ambulance, at the casualty clearing
station, at the hospital on the lines of communica-
tion in France, and at the base hospitals in England,
the problems of surgery are widely different.
Even the most skilful hospital surgeon of civil life
must pass through an apprenticeship at any of
these places before he becomes of the same value as
his house surgeon of pre-war days who has qualified
in war surgery. The experience of even a few
weeks may produce a wonderful revision of the
standard of values.

No work is done under such a variety of condi-
tions as the work of the field ambulance and of the

4 EARLY TREATMENT OF WAR WOUNDS

regimental medical officer. The circumstances in
which a field ambulance finds itself, and the resources
at its disposal, are so different under the conditions
of ordinary trench warfare and of a big engagement*
that it is impossible, as in the case of other units,
to lay down hard and fast rules that are of more or
less universal application. What is easily attained
under ordinary conditions may be absolutely im-
possible during the heat of a battle, and methods of
treatment, that are well within the reach of ambu-
lances working in one portion of the line, may be
entirely impracticable to those working under less
favourable conditions. For this reason, objections
may be raised that some of the methods of treat-
ment laid down in the following pages are impossible
at times of great pressure. This is, unfortunately,
only too true, but it affords no argument against an
attempt to reach the high-water mark of treatment
under the most difficult conditions. At the same
time, it must be remembered that in many cases
what was once considered impossible to achieve in a
field ambulance has now become common practice.
The higher the ideal of treatment is set, the better
will be the standard that is normally reached.

The Importance of Preventive Work. — As indi-
cated, enormous difficulties beset advanced work,
especially during severe fighting. The conditions of
warfare demand, to put it bluntly, that wounded
men shall be got out of the way so that supplies
of reinforcements, ammunition, and food to the
fighting line are not interfered with. Rut while the
primary function of advanced medical units is to

WOUNDED MEN AT ADVANCED UNITS 5

clear the wounded as rapidly as possible, yet the
enormous importance of preventive work must
constantly be kept in mind. The effects of treat-
ment of the wounded man at the earliest stages are
reflected in the whole course of his subsequent ill-
ness. The influence of efficient early treatment
cannot be overestimated. The fate of a life or limb
is often determined before the arrival of the wounded
man at the casualty clearing station, and no subse-
quent surgical skill can undo an error that has pre-
viously been committed. The “results ” of the casu-
alty clearing station, to a great extent, reflect the good
or the bad work of the forward units. Treatment
begins when the patient is first seen, and not in the
operating theatre. The prevention of early compli-
cations gives a man a good start in his struggle.
Only the most necessary procedures can be carried
out, but these must also he the best possible.

Intercommunication with units farther back will
ensure the highest efficiency and improvement.
Reports as to the condition in which patients arrive
there should be furnished and treatment at the more
advanced units should be amended, if necessary,
according to the indications given.

The three great factors for evil which have to be
combatted in these early stages are shock, haemor-
rhage, and sepsis, which react on each other in marked
fashion.

Shock— The intense surgical shock from which
some of the wounded suffer must be seen in order
to be appreciated. Primary shock from the injury
is aggravated by unavoidable early handling and by

6 EARLY TREATMENT OF WAR WOUNDS

transport of the patient. This fact is brought home
in a negative way by the observation that a man
with a fractured femur who lies out for a day or two
after being wounded, arrives at the casualty clearing
station in better condition on the whole as regards
pure shock than one who is picked up and trans-
ported without delay. A comparatively smooth rail-
way journey has a deleterious effect. How much
worse is the effect of transport down uneven trenches,
over rough country, and along bumpy roads ! A
wounded man left lying out keeps his limb at rest
and recovers from the first shock of the injury.
Close attention must be paid to these indications
because other considerations compel the immediate
removal of the patient to a place where he can be
operated upon to the best advantage Every effort
must be made to prevent the summation of painful
stimuli, which transport inevitably provides, from
producing fresh shock or intensifying, beyond the
patient’s endurance, the shock already present. The
most important elements in combatting the develop-
ment of profound secondary shock arc rest, both
mental and physical, and warmth. Rest during the
journey is procured by proper fixation and efficient
support of the injured part and prevention of jarring
bumps. Complete rest to the patient is out of the
question at this stage and therefore the aid of seda-
tives has to be invoked, and should be used as early
as possible in order to render him less sensitive.
Morphine is very valuable, but its purely depressing
effect on the vital centres and on metabolism, which
are in these cases already too often at a low ebb.

WOUNDED MEN AT ADVANCED UNITS 7

constitutes a disadvantage. Omnopon, or any similar
extract of opium under a different name, is prefer-
able, because this depressing effect is not manifest
to anything like the same degree. Two-thirds ot a
grain of omnopon is equivalent in sedative action to
about one-fourth to one-third of a grain of morphine.
At this point one may say that much of the benefit
of the sedative is lost if the patient is at once sent
off on his journey. He should be detained, it pos-
sible, for fifteen minutes or more, until the injection
has taken effect. Every dose of morphine or omno-
pon, and the time at which it is given, should be
noted on the field medical card. It is only in special
cireum stances that precautions against shock, other
than those mentioned, can be employed before the
patient reaches the advanced dressing station. These
other remedies will be described later. {See
Chapter III.)

General anaesthetics should be used as little as
possible. Chloroform and etKer decrease the already
unstable nervous control and predispose to shock
If such an anaesthetic is compulsory, patients should
be retained, if possible, for several hours there-

after, * , .

Acute Sepsis. — The sepsis most to be feared m
very early stages is caused by gas forming bacilli.

Gas gangrene develops rapidly in parts which are
deprived of circulating blood; witness the extra-
ordinary rapidity with which the whole body becomes
affected after death. Interference with the circula-
tion is brought about in varying ways, each con-
tributing to the loss of the normal supply of oxygen

8 EARLY TREATMENT OF WAR WOUNDS

to the tissues. The most important should always
be borne in mind. The wounds most likely to be
attacked are those in which there lias been consider-
able destruction of muscle tissue accompanied by
interference with the blood supply. The specific
bacilli develop most rapidly in lacerated muscle
deprived of circulating oxygenated blood. Wounds
of the buttock, of the thigh, and of the lower ex-
tremity generally, are particularly liable to gas in-
fection owing to the anatomical arrangement of their
vessels. Shock or severe haemorrhage predisposes
to the development of the infection owing to the
slowing and enfeeblcment of the circulation. On
this account shocked cases frequently slide very
rapidly into a condition of pfofound toxaemia. The
patient is too often with the devil and in the deep sea.
If the main vessel of the limb is injured the danger
is still greater, because, owing to general enfeeble-
ment, efficient collateral circulation is so delayed that
before it is established the infection often obtains a
firm hold. Pressure of blood-clot renders the walls
of the wound anaemic, while inflammatory effusion,
both liquid and gaseous, adds a steadily widening
vicious circle. Prolonged use of a tourniquet has
a disastrous effect,

/The prompt recognition of early signs of gangrene
in a wounded man, followed by his immediate evacua-
tion to the casualty clearing station, accompanied by
a warning note, may result in the saving of a life
that must otherwise inevitably be lost. It must be
remembered that the presence of gas in the tissues
in sufficient amount to give rise to the phenomenon

WOUNDED MEN AT ADVANCED UNITS 9

of crepitation is a late sign in gas gangrene. By the
time that crepitation exists, gangrene is usually well
established and the patient’s life is endangered. An
early and very suggestive sign is rapid, and somewhat
inexplicable, increase in pain accompanied by marked
swelling. The characteristic sweet and offensive
odour is also present at an early period. On examin-
ing the wound it is found to be dirty, dark in
colour, and on pressure gives forth dark, dis-
coloured, evil-smelling blood, sometimes mixed with
' bubbles of gas. The skin around may already be
bronzed and swollen. Frequent general signs are
vomiting, thirst, a rise in the pulse rate and symp-
toms of intense toxaemia. Sometimes the checks are
llushcd to a dusky red, but as a rule tbe skin acquires
early a pale lemon colour.

Hemorrhage.— One need not do more than draw
attention to the fact that haemorrhage predisposes
to shock and will aggravate shock already present.
On the other side, the only good thing that can be
said of shock is that by enfeebling the circulation
it mav prevent so great a loss oi blood as might
otherwise occur. It should always be remembered
that every ounce of blood is of the greatest impoi-
tance to the wounded man. An extra ounce lost
may be like the fata! straw on the back of the
camel.

Shock in Slightly Wounded.— Such remarks apply
to all severe wounds, but in a number of slight wounds
the element of shock also becomes manifest, some-
times in a very great degree. It is remarkable
also how in some patients shock suddenly develops.

10

EARLY TREATMENT OF WAR WOUNDS

especially during transport, for no evident reason.
It seems that their power of endurance suddenly
breaks down. Such men are often of a highly strung
nature, excitable and talkative while being dressed.
They do not usually 7 complain of pain, and there may
be no haemorrhage or other shock-producing factor
present. It may be that a sufficient injection of
sedative will prevent the onset of such shock.

General Treatment

The Condition of Wounded Men. — As already

stated, the great majority of the severely wounded
give evidence of the existence of some degree of
shock or collapse, and attention to their general con-
dition is as important as attention to their wounds.
Shock is generally due to the combined action of
several causes, amongst which the most common are :
(1) haemorrhage, (2) exposure to cold, wet, hunger,
and fatigue, (3) pain and anxiety, (4) the presence of
multiple injuries, (5) the injury of some important
organ, as in lesions of the trunk and head. Next to
the actual injury, the journey from the trenches to
the casualty clearing station is the most potent factor
in producing shock, and every effort must be made
to render this journey as easy as possible for the
wounded man. This can only be done by attention
to innumerable details, which, considered separately,
may seem insignificant, but taken collectively may
make the difference between life and death to the
patient. Viewed in this light, no attention that con-
tributes to the wounded man’s comfort during bis
journey is so trifling as not to merit care and con-

WOUNDED MEN AT ADVANCED UNITS II

side rat ion. The good work of an ambulance rests
on attention to these details rather than on the
performance of surgical operations.

As these points in general treatment are of such
paramount importance, they will be considered under
separate headings.

Care of the Wounded in Front of the R.A.P.—

Regimental stretcher bearers should be instructed in
the danger of wound shock and taught the urgency
of preventing unnecessary loss of body heat during
the carry back to the aid post.

To obviate this loss, they should be supplied with
a certain number of waterproof sheet-blanket packets,
each packet consisting of one blanket wrapped up in
a ground sheet. These are strapped to the stretcher
ready for use, and are returned with the R.S.B.s as
soon as thev have delivered the wounded man at
the aid post. When the aid post is situated at some
distance from the front line, these measures to pre-
vent earlv exposure are doubly necessary. The
occasional" loss of a blanket will be amply compen-
sated for by the saving of wounded men who would
otherwise die from the effects of being carried on bare

stretchers. , , , ■

Regimental stretcher bearers should also be in-
structed in the gentle handling of patients and in the
application of splints. Rough or unnecessary move-
ment, as one of the most potent factors m precipitat-
ing shock, must be avoided.

In certain cases where the carry to the aid post is a
long one, it may be possible to keep a small supply o
splints at, for example, the company headquarters.

12 EARLY TREATMENT OF WAR WOUNDS

Warmth — Th ere is no measure which is of such
vital importance to a seriously wounded man as the
provision of warmth. The first complaint heard in
a regimental aid post is almost always of cold, and
throughout the wearisome journey to the casualty
clearing station the same complaint is repeatedly
voiced. Many stretcher cases arrive at the clearing
station so cold that the pain of their wounds has
been relegated to the background, and in severely
shocked cases the surface temperature may have
sunk to as low as 90°. During winter months the
mortality from shock materially rises as the result
of the increased cold. The necessity for mobilizing
every means of warmth in the forward area is so
great that no excuse is offered for dealing with the
matter in detail.

Blankets, — The chief protection of the wounded
man against cold during the first part of his journey
lies in the liberal use of blankets. At no time is the
loss of heat more rapid than during the first two
hours after wounding, and every effort must be
made to prevent exposure to cold at this period.
Nothing is more striking than the deterioration in
condition that takes place when a stretcher case has
been sent on his journey without a blanket beneath
him as well as one on top. There are difficulties
attending the maintenance of a good supply of
blankets in a regimental aid post, but, except in a
big engagement and a rapid advance, these difficulties
arc not insuperable. Even in the latter event, if
R.A.M.C, stretcher squads never make the return
journey empty-handed, but carry up as many blankets

WOUNDED MEN AT ADVANCED UNITS 13

as possible, some attempt may be made to cope
with the exhaustion of the regimental aid post
blanket supply. During quieter times the difficulties
arc much less, and it should be possible to maintain
a sufficient reserve to allow of every stretcher case
being provided with a minimum of two blankets.
In cold weather and with shocked cases a third must
be added.

Method of Folding Blankets.— In order that the
practice may be universal and that the maximum
advantage may be obtained from the blankets, the
following routine should be adopted and adhered to.

Fig. 1.

Immediately on the completion of the dressing and
of the cutting away pf blood-soaked clothing, the
patient should be carefully lifted on to a clean and
prepared stretcher. Two blankets are previously laid
on the stretcher? each with a double fold correspond-
ing with the width of the stretcher. The breadth oi
the blanket is used? as it is sufficient to reach from
the foot of the stretcher to the position occupied b>
the pillow. Blanket beneath the pillow is wasted.
If the breadth be not quite sufficient? the two blan-
kets need not exactly coincide? but the upper one
may be placed slightly higher on the stretcher than
the lower. {See fig. i.)

14 EARLY TREATMENT OF WAR WOUNDS

While awaiting use the free portions of the two
blankets may be rolled up and laid on the stretcher.
When required these free portions are opened out,
the patient is lifted on to the two double folds, and
the free portion of each blanket wrapped in turn
round him. The wounded man by this arrangement
has four thicknesses of blanket beneath him and
two on top. If his jacket lias been removed, or if
lie has an overcoat, it is laid as an extra covering
over his feet. In rainy weather a mackintosh sheet

LOnonecuNALtr tocoed blanket

+

Fig. 2.

is added to protect him from further wet. On arrival
at the advanced dressing station, or before leaving
the aid post, if the supply permits, a third blanket is
added* The portions of the blanket wrapped round
him are undone and the third blanket, folded along
its length, is placed over him* (See fig. 2*) The lower
extremity of this is tucked well in beneath the man s
feet and the two corners brought round and secured
above the legs by a safety pin* After the addition
of the third blanket the free portions of the other
two are again wrapped round him* lie has now
four thicknesses of blanket above him as well as
below*

WOUNDED MEN AT ADVANCED

This method of using blankets has three advan-
tages. (1) By having a routine procedure, to be
employed in every case, there is less likelihood of men
being evacuated insufficiently protected against cold.
(2) The maximum benefit is obtained by using
blankets in this manner. (3) Blankets so adjusted
do not work out of position in the way they do when
other methods are employed.

When space permits the blankets may be thoroughly

LOWEST

BLANKET

I . t

LONGITUDINALLY FOLDED BLANKET

mtL

Fia. 3,

warmed before use by having the prepared stretcher
placed over a stove, as suggested on page 20.

Every effort must be made to store blankets in as
dry a spot as possible. This is especially important
in the case of regimental aid posts. At every casualty
clearing station arrangements must exist for the
drying of blankets so that no wet one need ever be
returned to a field ambulance. At the main dress-
ing station of an ambulance an excellent drying
room may be constructed by utilizing the heat of an
incinerator. The incinerator is built into the end
of a hut, the Hue being carried along its middle

X .

* 1 " • , ; •

EARLY TREATMENT OF WAR WOUNDS

a n d o u t
t h rough
the roof
at the op-
posite end*
If it is pro-
perly con-
structed,
even fecal
material
may be
b u r n t in
the incine-
r a f o r
wit hout
^ any smell
^ being no-
t i ceable
inside the
hut. A
d r y i n g
room of
this de-
scription
is econ-
omical in
fuel, effec-
tive, and
of great
value in
overcom-
ing one of

WOUNDED MEN AT ADVANCED UNITS IT

the difficulties incidental to clearing the line in wet
weather* It may be modified by addition of a tank
for hot water and steam disinfector, (See fig. 4*)

Removal of Wet Clothing,— During bad weather
wet clothing should be removed as early as possible
and the wounded man put into a dry suit of pyjamas*
Sometimes this may be done at an advanced dress-
ing station, but often no arrangements for the change
into dry clothes are to be found further forward
than the main dressing station* The advantages of
an early change are enormous, and every effort must
be made to accomplish it as far forward as possible.
It is impossible to get a wounded man warm while
he is surrounded by a cold compress of wet clothing,
and to get a man warm is as important an item in
ambulance treatment as to dress his wounds.

In any ease, during wet weather the boots and
socks should be removed at the aid post, and the
feet well rubbed. In cases of severe shock in frac-
ture of the femur it is advisable to leave the boot
on the injured limb. The handling entailed by re-
moval of a wet boot and sock may seriously increase
the shock.

Hot Water Bottles. — The ideal would be to send
every severely wounded man down from the regi-
mental aid post provided with hot water bottles*
Unfortunately tins ideal is sometimes difficult of
attainment, not only because the supply of rubber
bottles fails, but also because in many cases the
means of obtaining hot water are very limited.
During big engagements such a plan is obviously im-
possible, but during quiet times it is usually feasible.

2

18

1

EARLY TREATMENT OF WAR WOUNDS

When the supply of rubber bottles gives out, ordinary
water bottles and empty wine or beer bottles may be
pressed into the service. When there is difficulty
in obtaining hot water, licit bricks, wrapped in
sandbags, form the best substitute. The water
bottles or bricks are placed between the layers of
blankets so as to avoid the danger of burns. The
perineum and the axillae are the best regions to
which to apply heat. Particular care must be taken
to protect from burning in the ease of unconscious
or very collapsed patients, and in those suffering
from paraplegia. Under wet clothing or bottle
coverings scalding will occur especially easily.

There are very few advanced dressing stations which,
during ordinary times, arc not in a position to pro-
vide some form of artificial heat for the severely
wounded passing through. It. must be borne in mind
that the employment of the light railway is becom-
ing more and more common in the evacuation of the
wounded, and that these light railway trucks are
sometimes lacking in heating arrangements. A night
journey in an unheated railway wagon is at all
times an uncomfortable ordeal, and to the severely
wounded man, insufficiently wrapped in blankets,
and unprovided with hot water bottles, it is only
too likely to be fatal.

Heating of Conveyances. — It is during the earlier
parts of the journey towards the casualty clearing
station, and while travelling in Decauville trucks
and in barges, that hot water bottles are most
needed, and it is unfortunate that this should just
be the period when the greatest difficulty exists

WOUNDED MEN AT ADVANCED UNITS 10

in providing them. Motor ambulances, with the
exception of the Ford, are now heated by means of
their exhaust, and this modification lias undoubtedly
resulted in the saving of many lives. In cold
weather the production of heat from the exhaust
may be accelerated by running the car for a time
on the low gear. Although it is inadvisable to
employ this method in the case of the Ford, a simple
expedient will help to remedy the defect, and, as
these ears often evacuate cases from a very forward
position, will at the same time provide means of
heat when other sources are unavailable. Let every
Ford car carry two rubber bottles as a permanent
equipment, to be filled when required from its own
radiator. A convenient tap exists underneath, and
the hot water removed may be replaced from the full
petrol tin of water carried for that purpose. This
expedient for obtaining hot water in ease of urgent
necessity, and when no other source exists, is not
necessarily confined to the Ford.

The Heating of Dressing Stations— As the heating
arrangements of dressing rooms are usually very
meagre, care must be taken to expose the wounded
man as little as possible during dressing or when
giving him an injection. Much can be done in pro-
tecting the patient from draughts from doors or
faulty windows. When he is suffering from multiple
wounds, only one portion of his body should be ex-
posed at a time, and the dressing completed as rapidly
as possible. It is an excellent plan to place a small
oil stove midway between the two trestles upon
which the stretcher rests. Whatever the tempera-

20

EARLY TREATMENT OF WAR WOUNDS

ture of the rest of the room may he, this arrangement
will provide a current of warm air which rises fiom
the stove, and diffuses round the stretcher at the
time when the man, exposed for Ins dressing, is most
susceptible to cold. By allowing the free ends of
the two lower blankets to fall down on each side of
the stretcher, a chamber of hot air is formed beneath
it. This arrangement can easily be employed far
forward, even in an aid post, where a Primus or
Beatrice stove can be used as the source of heat.
Two bricks are placed on the stove to prevent burn-
ing of the stretcher. These bricks, after cooling to a
suitable temperature, can be covered with sandbags
and placed between the layers of blanket and sent
down with the wounded man, in lieu of hot water
bottles.

The hot air may be made to circulate over the
patient by means of the following simple device.
The already warm folds of the blanket, hanging on
each side, are placed over the man. One or two
stretcher bars arc fixed to the stretcher near the
middle. A piece of Gooch splinting, four slats wide,
is tied to the horizontal part of the suspension bar,
so that the two outer slats of the Gooch fall on each
side of it and the ends of the splint project equally.
One “ tie ” in the middle is sufficient. A blanket, or
blankets, is now placed over the apparatus so that
the folds reach to the floor. Passages for warm air
arc thus provided on each side of the stretcher. The
warm air must be prevented from escaping at each
end of the stretcher by some means which need not
be described.

WOUNDED MEN AT ADVANCED UNITS 21

Pyjamas, etc., may be hung under the stretcher
or placed on the framework supporting it, and thus
hot, dry clothing is ensured.

For the sake of economy of space some such method
of warming the patient is preferable to those illus-
trated.

Hot Air Baths, In dressing stations where there
is accommodation for retaining, if need be, a case
that has been admitted in a state of cold and collapse.

a ** cooking ” apparatus on the lines of those in vogue
at casualty clearing stations may easily be impro-
vised, Two methods of manufacturing extempore
“ cookers ” are given. (See fig. 5.)

In the above ease (fig, 5), where a Primus or a
Beatrice stove is the available source of heat, the
hot air is collected in an oil drum. A window is cut
in the drum below, and an iron or asbestos pipe,
let into it above, conducts the heat to the patient.
Two or more patients may be heated from the same
drum by multiplying the pipes. The cradle in the
illustration has been made from the aluminium
splinting material in the fracture box. This is, with

Qii^

DRUM

22 EARLY TREATMENT OF WAR WOUNDS

advantage, reinforced by the addition of two tin
sheets A and R, cut out from a biscuit box.

Fig. 6 shows a suitable arrangement when the heat
is to be obtained from a small oil stove such as supplied
by the Red Cross Society. If no other cradle is
available the blankets may be kept off the patient
by means of two or three stretcher suspension bars.
In this case, instead of an oil drum, a petrol tin is

SUSPENSION bars

fig. 6.)

In a very short time, by means of otic of these
forms of cooker, the temperature of a cold or col-
lapsed patient may be raised to normal, and with
the rise there takes place a corresponding improve-
ment in his general condition. Indeed, few things
arc more gratifying than the improvement that
takes place in the condition of a shocked patient
during his stay in a dressing station, under the influ-
ence of warmth, quiet, and freedom from pain. It
must be pointed out, at the same time, that there
is danger of overdoing the heating, and of thereby

WOUNDED MEN AT ADVANCED UNITS 23

causing sweating and discomfort which may exhaust
the patient. Careful supervision should prevent
this {see page 93).

Avoidance of Exposure.—At all stages of the
journey the same care must be exercised in guarding
the wounded against cold. During times of great
pressure dressing rooms are so crowded that it is
necessary to keep large numbers of stretcher cases
waiting outside until their turn for dressing arrives.
Evcrv effort must be made to provide these men
with what shelter is available, and at any rate to see
that blankets and, if need be, waterproof sheets, arc
freely provided. The same precautions must be
taken in the case of those awaiting evacuation.
Moreover, in cold weather, when the patient is
placed in the ambulance the canvas flap must be
properly secured and not raised again till just before
the stretcher is lifted out. Severe cases should in-
variably ride in the lower berth, not only because
they arc nearer the warm exhaust, but also because
they are subjected to less lateral swaying in that
position.

The Administration of Fluids and of Nourishment.

— In view of the fact that the great majority of
severely wounded men have suffered a serious loss
of body fluid as a result of haemorrhage, it is ex-
tremely important to make good tlic loss as quickly
as possible. Thirst is, next to cold, the complaint
that is most frequently voiced in the aid post and
during the journey to the casualty clearing station.
Not only are fluids urgently demanded, but also
nourishment in some easily assimilable form, lor

/

24 EARLY TREATMENT OF WAR WOUNDS

many hours may have elapsed since the wounded
man had his last meal.

Unfortunately, the digestive organs of severely
wounded men are usually at fault, and not only is
digestion delayed, but vomiting is only too common.
The hot drinks most frequently provided are tea,
cocoa, oxo, and bovrii Of these, hot tea, with plenty
of milk and sugar, is by far the best. It is the most
generally acceptable, and at the same time the
least frequently vomited. Cocoa is rich in fats, and,
like oxo and bovrii, is usually not retained. Hot tea
and sugar supply heat, easily absorbed carbo-hydrate,
and a certain amount of stimulant in caffeine. The
use of alcohol, when a man is to be subjected to
further cold, is of doubtful value. When he has
reached his journey’s end and is in a warm atmosphere,
the dilatation of the superficial vessels brought
about by alcohol has no dangers, although in other
circumstances it may have.

Harm may be done by withholding fluid from a
very thirsty man, even though vomiting may pos-
sibly result from giving it.

To counteract the great disposition of the severely
wounded man to vomit, three conditions should be
observed. The first is that the drink should be
given after all disturbances and movements inci-
dental to the dressing have been completed. The
second is that the wounded man be warm, and the
third that drinks be given in small quantities at a
time. When these conditions are observed, vomiting
is diminished by 50 percent. If cocoa be employed,
the preparation of peptonized cocoa and milk

»

WOUNDED MEN AT ADVANCED UNITS 25

supplied by the Red Cross Society is preferable to
the ordinary variety.

When, on account of persistent vomiting, or of the
presence of other urgent symptoms, means of mak-
ing good the loss of body fluids arc required, two
methods are available in a regimental aid post, or an
advanced dressing station — the use of rectal and ol
subcutaneous salines.

Administration of Sodium Bicarbonate. In pre-
vent or counteract acidosis, sodium bicarbonate
should be given to every seriously wounded or shocked
man. On account of the tendency to vomit which
such a patient displays, it should not be given, when
circumstances permit of his being retained, until be
is warmed up or otherwise resuscitated. It may be
given by mouth in doses of 3C-60 grains in water
or sweetened tea, by rectal injection, or intra-
venously. In the last case it should not be given
with gum solution, as it will precipitate the calcium
salts in the gum.

Rectal Salines.— These have the advantage over
subcutaneous injection in that they are easily ad
ministered without fear of accidents from lack of
aseptic precautions. Their disadvantage lies in the
fact that in a certain number of cases the rectum is
found to be loaded, and the saline is not retained.
The injection must be warmed and run in very slowly.
Glucose (5 per cent.) forms a useful addition to the
saline, especially when the wounded man is suffering
from starvation as well as loss of fluids. Sodium bi-
carbonate, 2 teaspoonsful to the pint, may be used
with advantage instead of ordinary “ saline’ infusion.

26 EARLY TREATMENT OF WAR WOUNDS

Subcutaneous Injections, — Although a subcu-
taneous injection entails the employment of aseptic
methods it does not necessarily demand the posses-
sion of a special apparatus. When other means are
not at hand all that is required is an ordinary ear
or new Higginson syringe, an antitoxin needle* a
small connecting piece of rubber tubing, and a bottle
of sterile saline. The injection is given by means of
the syringe which, if necessary, may be disconnected
from the rubber tubing, refilled, and connected up
again. The whole outfit must be sterilized by
boiling before use. The site of puncture is rubbed
with picric acid (3 per cent.) in spirit. In order
to prevent infection of the puncture from dirty
clothing, the needle may be pushed through a few
folds of sterile gauze placed on the skin.

Intravenous Infusion of Gum Solution. — In cases
of severe haemorrhage, in which the journey to the
casualty clearing station is likely to have disastrous
consequences, a solution of the gum acacia, 6 per
cent,, supplied in sterile bottles, should be given
intravenously, 500-750 c.c,, according to the esti-
mated loss of blood. The viscosity of this solution
prevents its escape from the circulation, as occurs
at once in the case of simple saline solutions.

Transfusion of Blood.— This has been successfully
carried out in field ambulances, but should only be
undertaken by those who are thoroughly familiar
with the necessary technique.

The Relief of Pain. -The relief of existing pain and
the avoidance of any action likely to produce further
distress is not only of importance on humanitarian

WOUNDED MEN AT ADVANCED UNITS 27

ground, but also as a therapeutic measure. What-
ever be the true pathology of shock, it is un-
doubtedly provoked and increased by a summation
of sensory stimuli bombarding the higher centres.
The unskilful handling of a broken limb or the rough
treatment of a painful wound is sufficient to plunge
a wounded man into a condition of surgical shock.
In a regimental aid post or advanced dressing station,
apart from ordinary attention to the wound, only
that which is strictly necessary for the stopping of
haemorrhage or the splinting of a fracture should be
attempted. Manipulations purely for the sake of
arriving at a more precise diagnosis arc not justifi-
able. The more skill is exhibited in the dressing
of an awkwardly placed wound or in splinting of a
difficult fracture, the less will be the shock resulting
therefrom, and the smaller the drain on the wounded
man’s already depleted reserves of nervous energy.

Morphine. —Properly used, opium is the most valu-
able drug available in the early treatment of severely
wounded men. Before discussing the indications for
the use of morphia it is advisable to make certain
observations on the method of giving it. In the fust
place, the method of administration by means of
tabloids laid under the tongue must be absolutely era-
dicated. The buccal method has nothing to commend
it, and is a source of confusion further down the line.
A note on the tally, merely to the effect that a man
has received £ grain of morphia, may mean either
that lie has been given a hypodermic injection or that
two tabloids have been placed under his tongue. In
the latter ease it is impossible to know if the drug

28 EARLY TREATMENT OF WAR WOUNDS

has been absorbed. Frequently the wounded man
spits it out, and even if he retains the tabloids the
inhibition of the gastric functions that occurs in
shock renders absorption a matter of doubt.

In spite of these many disadvantages the buccal
method is still in use amongst regimental medical
officers. The reason advanced for its employment is
that it avoids the difficulty of sterilizing a syringe

in an aid post. This fear of sepsis is surely an
exaggerated one. Accidents resulting from faulty
technique in giving a hypodermic injection are ex-
tremely rare, even when dealing with anti-tetanic
serum. In the case of morphia injections they
scarcely exist. Moreover, by a simple device, the
difficulty may be entirely eliminated. Every regi-
mental and bearer officer should carry two bottles of
the kind shown in the accompanying diagram. (See

Fig, 7,

fig. 7.)

WOUNDED MEN AT ADVANCED UNITS *29

The first of these is a stock solution (2$ per cent.)
of morphia in a rubber capped bottle of the type
in which antityphoid vaccine is now supplied. The
second is a bottle with a perforated cork bearing a
hypodermic syringe. The needle of the syringe
projects into alcohol, and is thereby kept sterile and
always ready for use. When an injection is required
the cork with its syringe is removed and loaded from
the first bottle. A complete syringeful is equivalent
to \ grain of morphia.

A second error that is extremely common in the
matter of morphia is that it is not administered
early enough. Not oidy is the maximum benefit of
morphia obtained by early administration, but also
the maximum safety, (.liven early, morphia assists
in damping down the painful stimuli that are partially
responsible for exhausting the badly wounded man.
Later on, changes occur in the patients’ metabolism
that show themselves by a diminished alkalinity of
his blood. To counteract the impending acidosis
the respirations are increased in amplitude and fre-
quency. Morphine is likely to interfere with this
natural mechanism, and should therefore be given
at an early period when its administration is less
likely to have this disadvantage, and may indeed
delay the onset of acidosis. On the arrival of a
wounded man at the regimental aid post the first
consideration should be his general condition rathei
than his wounds. If he is suffering from severe pain
an injection should be given immediately, and he
should be left quiet for a quarter of an hour (unless
haemorrhage is taking place) until the drug has had

30 EARLY TREATMENT OF WAR WOUNDS

time to act. If the injection be given intra-muscu-
larly its action will be still more rapid. Other eases
can be attended to while the injection is taking effect.

The benefit of an injection of morphine is to a
great extent lost if the necessary environment of
warmth and quiet be not at the same time provided.
Although the latter is not always possible to achieve
in an aid post or ambulance dressing station, an
effort should be made to provide some corner in
which a wounded man may be as little disturbed
as possible whilst the injection is taking effect.

As a general rule it is found that nothing under
a half-grain initial dose is of any use when dealing
with a man suffering from severe pain, and provided
it be administered early there is little danger in
giving such a quantity. It is in deciding when to
repeat that difficulties arise. Extreme restlessness
and the persistence of severe pain are the best indica-
tions, Persistently restless cases invariably do badly,
and are not only a danger to themselves, but are
liable to excite other wounded men in their neigh-
bourhood, In addition to these considerations the
existence or absence of means of providing the neces-
sary accompaniment of warmth and quiet must be
allowed weight in arriving at a decision as to whether
it is advisable to repeat the injection. If it is neces-
sary to evacuate the wounded man immediately after
his injection and to expose him to all the stimuli of
a motor journey over indifferent roads, it is doubtful
whether the injection will be of much value.

Cases in which there is marked cyanosis and a
suggestion of pulmonary trouble should not be given

WOUNDED MEN AT ADVANCED UNITS 01

morphia unless absolutely necessary. The best con-
trol for the giving of morphia is the condition of the
respirations (rate and depth), and not the size of
the pupils.

Other narcotics besides morphine may be used,
notably omnopon and scopolamine. The former
drug, having a less depressing effect than morphine
on the vital centres and on metabolism, is of great
value. Scopolamine lias probably more action on
the mental faculties, and is useful in excitable cases.

Stimulants. — Drug stimulants as a class have been
tried and found wanting in the treatment of most
cases of wound shock under the unfavourable condi-
tions of a push,” Hot coffee per rectum and small
quantities of alcohol by mouth are still recommended
by some (see page 24),

The Psychology of the Wounded Man. — The men-
tal state of a wounded man is always worth
studying. Psychological disturbance is most marked
during the period immediately after wounding, and
may take the form of excessive fear of being hit
again, irritability, or psychic shock. As a rule, if the
wound is slight, this condition soon wears off, but
sometimes, when an element of shell shock exists, it
may persist. It’ must be remembered that, although
in most cases of surgical shock, the higher faculties
are usually somewhat depressed, other cases exist, of
the excitable variety, in which these faculties, and
especially that of hearing, are extraeidinarily acute.
Remarks not intended for their ears are sometimes
overheard by such patients, and if they are of an
alarming nature may have an injurious effect upon

32 EARLY TREATMENT OF WAR WOUNDS

them. Emotional stimuli are only secondary to
sensory stimuli in provoking shock, and the sudden
realization that he has lost, or will lose, a limb may
react in an alarming manner on the general condition
of the wounded man.

Evacuation, — It is often a matter of some diffi-
culty, when dealing with cases not suffering from
injuries demanding immediate operation, but who
are at the same time severely shocked, to decide
when they should be evacuated. This problem is
especially difficult during quiet times when pressure
of' work does not prevent retention, if necessary, of a
wounded man in an aid post or a dressing station.
No dogmatic rules can be laid down on such a sub-
ject, as the correct answer can only be arrived at by
a consideration of various factors, such as the accom-
modation available, the possibilities of providing
warmth, the condition of the wounds, the general
state of the wounded man, the distance of the casualty
clearing station, and the presence or possibility of a
“ gas attack,’ 5 If, however, the patient is cold, if
his pulse is above 130, and, above all, if his lips
and nails are at all dusky in hue, it is highly advis-
able to retain him for an hour or two, and to get
him warmer before sending him on the next stage
of his journey. Facilities for evacuating have be-
come so good that it is probable that a certain
number of exhausted men are lost actually through
the rapidity of their journey to the casualty clearing
station. It is surprising what improvement takes
place in the general condition of a severely wounded
man when he is allow ed an hour’s rest in an advanced

WOUNDED MEN AT ADVANCED UNITS 33

dressing station and begins to react to the magic of
warmth and freedom from pain. One hour of such
rest, even if it be unaccompanied by actual sleep,
is worth more to him than all the therapeutic remedies
of the pharmacopeia. It may allow a severely
wounded man to support the remainder of a journey
that might otherwise easily prove fatal*

Methods of Transport. — -Three sorts of mechanical
transport are employed in the evacuation of wounded
from the, forward area — motor ambulances, light
railways, and canal barges. Each of these has its
advantages and disadvantages. The most commonly
used motor ambulances are speedy and warm, but,
when the roads arc poor, the jolting which takes
place is a serious disadvantage. Light railways and
canal barges, on the other hand, although they are
free from this defect, have the great handicap of cold.
In addition to this, they are slow, and, as they are
not usually planned merely for the use of the wounded,
the route they follow is frequently a devious one.
For this reason, when a choice is offered, and the
roads are good, the motor ambulance is to be pre-
ferred for the majority of wounded.

No little skill is required to load a wounded man
into an ambulance car without jolting him and caus-
ing him pain. Orderlies should be specially prac-
tised in this work and have impressed upon them
the importance of handling all stretcher eases with
the greatest care. It is also worth remembering that
an ambulance with its full complement of cases on
board rides much more easily than with a light load.
Finally, the degree of inflation of the pneumatic
3

84 early treatment of war wounds

tvrcs i*t not without effect on the jolting of the car-
Uics is not pounds is suitable during

A pressure of about sixi\ I with nut

winter weather and favours the patient without
being unduly hard on tyres. Anything over this,
although it may assist the life of the tyre, may
tie reverse effect on that of the patient, as it pro-
duces increased jolting and discomfor .

The position of the patient during transport is
often important in that it may obviate a sudden y
from an uneven road. For example, a man with a
fractured arm will often ride more comfortably
sitting than when lying down. Jolting is dissipated
bv hfs Yielding body before the shock reaches his
arm In the same way some head cases, with con
siderable though unsuspected damage to the brain
often arrive as “sitters” in extraordinary good
condition. Sudden sharp bumps or lateral move-
ments of the head arc particularly bad in cerebral
injuries. Such cases must usually be sent \\ mg
d o W „ An extra pillow or folded blanket should be
placed under the head, and, especially if the man is
unconscious, side supports should be so arranged as
to prevent coarse lateral movements during lurches
of the car. For similar reasons, in the case ol fac-
tored femur the Thomas’ splint should be slung so
as to allow a certain amount of lateral play, sott
stretcher pillows are to be had from the lied Cross So-
ciety and are a great source of comfort in many cases.

Local Treatment

Treatment of Wounds— Much discussion took place
during the earlier periods of the war as to the best

WOUNDED MEN AT ADVANCED UNITS 35

form of dressing and the most effective lotions to be
employed in the treatment of wounds. It was
hoped that by the early use of suitable disinfectants
much would be done to combat the onset of sepsis.
It has been found that antiseptics per se have but
little influence in this direction, and that the best
hope of averting the danger of severe sepsis lies in
early and efficient operation. The use of ordinary
disinfectants and impregnated dressings is of little
or no value in most cases until such operation has
been carried out. Eusol and similar solutions arc
too evanescent in antiseptic action when in con-
tact with the tissues to make their use u worth
while/’ and Carrel’s method is out of the question
at this stage.

Field ambulance surgery is a surgery of emergency,
and no operation that can be safely postponed until
the arrival of the wounded man at the casualty clear-
ing station must be undertaken in the less favourable
surroundings of the more advanced unit. When
time permits, during a rush, and the immediate
evacuation of the patient is not possible, an attempt
may be made to diminish sepsis by cleaning up the
surrounding skin and removing gross contamination
and blood clot from the exposed area of the wound ;
but unless a foreign body is actually visible and
easily dealt with, its removal should not be at-
tempted. For disinfection of the skin a 3 per cent,
solution of picric acid in spirit has been found superior
to tincture of iodine* If soap and water and picric
acid are available, no other ordinary antiseptics need be
provided for work in field ambulances during a battle.

36 EARLY TREATMENT OF WAR WOUNDS

Contamination is carried so far into the tissues
and recesses of a wound that syringing is of \ <.i\
doubtful value. It may even tend to distribute
infection to parts which previously were uninfected.

Dressings and their Method of Application. — As
already stated, antiseptics alone have little effect
in inhibiting the action of bacteria carried into the
depths of a wound. For field ambulance work pio-
bably plain sterile gauze and wool make the best
kind of dressing. Gauze impregnated with mercurial
preparations has been the cause of severe blistering
when applied over a skin previously painted with
iodine. If antiseptic applications are used at all
they arc probably best in the form of a Bismuth
Iodoform Paraffin Paste (bismuth subnitrate 1 part,
iodoform 2 parts, and liquid paraffin sufficient to
make a thin paste) or preferably of a 1 per cent, solu-
tion of iodoform in liquid paraffin. B.I.P.P. casts
a strong X-ray shadow, and therefore should not
be used I.P. (iodoform paraffin) is poured into the
wound in small quantity or is used to impregnate
gauze. Paraffin gauze may be stored in sterilized tins.
The tins should have holes cut in the bottom so that
excess of paraffin may drain away, be caught in an
outside tin, and used over again. The paraffin gauze
dressing is soothing, and does not stick. It can be
removed easily and without pain — an obvious advan-
tage in shocked cases.

The liquid paraffin dressing prevents the formation
of dry crusts under which organisms are likely to
flourish and discharges be retained. For this reason,
if paraffin is not obtainable, gauze is best applied

WOUNDED MEN AT ADVANCED UNITS 37

as a wet dressing, wrung out in saline. All lotions
should be warmed before use, even if the warming
has the effect of reducing their chemical efficiency.
When a wound tends to ooze, or when it is intended
to retain the gauze in position by means of adhesive
plaster, a dry dressing should be used.

Before applying a dressing to a compound fracture
it is advisable to remove carefully any visible com - '
pletely detached and jagged fragments of bone, or
foreign body, especially if these be in the neighbour-
hood of a blood vessel. When applying the dressing
the question of drainage must be borne in mind, and
any tendency on the part of the gauze to act as a
cork in retaining discharges should be avoided. In
dealing with large gaping wounds the dressing should
be laid loosely into the recesses, and several layers
of gauze interposed between flaps so as to prevent
their apposition, i.e. wounds that are already opened
should be kept open. When a small bridle of tissue
interferes with drainage it should be rapidly divided
with a scalpel or scissors, and the separation of the
opposing surfaces maintained by means of loose
packing. Application of a flat gauze dressing over
a deep valvular wound merely pens up discharge and
favours the spread of infection, if the depth of the
wound is not previously treated as described. Small
punctures of the skin by bullets require no special
attention. Between these and large gaping wounds
there are various gradations, which require commen-
surate judgment in treatment.

No more wool should be used than is strictly neces-
sary. Tlie employment of large quantities of cotton

88 EARLY TREATMENT OF WAR WOUNDS

wool, as well as being an extravagance, may result
in the masking of a serious haemorrhage* Sphagnum
moss pads make a very useful substitute for wool.
Precautions in applying Dressings, — Wounded
parts are apt to swell, and if tight bandages are
applied great interference with the circulation is apt
to occur, and serious results to follow. It has been
found, moreover, of great importance to support large

Fig, g.

and deep flesh wounds with splints, even although
no fracture is present. In such cases the encircling
bandage should be put on after the splint has been
placed in position. Finally, if extension is to be
applied to a fractured limb it should be applied
before the wound is bandaged. This precaution is
taken chiefly because of the swelling that supervenes,
but a more serious accident is liable to follow neglect
of this rule in the case of a fractured femur. The
application of extension sometimes dislodges a clot

WOUNDED MEN AT ADVANCED UNITS 39

occluding a large artery. If bulky dressings have
been bandaged to the wound, the haemorrhage that
occurs in such a case is likely to be obscured until
it is too late to save the patient.

When the accommodation in dressing rooms per-
mits, the use of folding wooden tables is recom-
mended. The top of the table should fit loosely into
the space between the stretcher poles and traverses.
This allows the poles of the stretcher to fall out of
the way, so that wounds of the trunk and lower
limbs arc more easily dealt with* {$£# fig. B.)

The Storing of Dressings*

- — Dressings should not
lie exposed to contami-
nation, especially when
the surroundings are those
of a regimental aid post
or an advanced dressing
station. The best method
of storing them is by means
of a Helby’s box. This is
made out of a four-gallon petrol tin and a tea tin,
which will be found to just fit, the one inside the
other. The two opposite sides of the tins are freely
perforated with holes so placed that when the two
tins arc in position the holes correspond* [See fig, 9.)

The drum thus formed is filled with gauze, and
placed in a steam sterilizer. On the completion of
sterilizing it is removed, and the outer tin readjusted
so that its imperforate sides are in contact with the
perforated portions of the inner one. The contents
are thus protected from contamination. To faeili-

40 EARLY TREATMENT OF WAR WOUNDS

tate opening, wire handles may be fitted to each tin.

A complete steam sterilizer for use with Helby’s
box may be made out of two biscuit tins and a butter
tin. By slightly bending one biscuit tin it can be
made to partially fit over the other. The butter
tin is. placed inside as a support and two inches of
water added. (See fig. 10.)

The Helby’s box in the “ open ” position is now

made to rest on the butter tin, the sterilizer closed,
and the whole placed on a Primus stove. The pres-
sure of steam generated inside tire apparatus is suffi-
cient to sterilize a box full of gauze, after half an
hour. This sterilizer withstands bacteriological tests
and exacts no skill in its manufacture.

When a rush of wounded is anticipated, time will
be saved by previously cutting gauze into squares
of some convenient size, such as six inches. For
each dressing as many layers as may be necessary are

WOUNDED MEN AT ADVANCED UNITS 41

lifted off the pile. In the case of a large wound the
layers are opened out; in the case of a small wound
they are folded to the required size* No more
cutting is required, and the dressings may be re-
sterilized in the above manner as often as required.

Bowls in which dressings* swabs, or sterilized dress-
ings are kept ready for use should be protected from
dust by means of covers cut out of tin. They are
sterilized by “ flaming.”

Over-dressing,— Patients have been needlessly an-
noyed by too frequent dressing of their wounds. In
badly wounded men the extra pain and disturbance
will tend to produce or aggravate shock. Routine
interference at every stopping place means waste of
time and material and of the energy and endurance
of the patient. Without definite indications, there-
fore, no dressing should be changed. Generally
speaking, these indications arc the presence of :

1. A first field dressing, which has usually been
applied over a dirty or imperfectly disinfected skin,
and, in many cases, has also been tied too tightly.
Sometimes, however, when the dressing is dry and
the patient's skin is apparently clean in the neigh*
bourhood of the wound, this dressing need not be
disturbed.

2. Soaking of the dressing with blood, mud, etc.

3. Unsuitable or imperfectly applied splints.

4. Too tight bandages interfering with circulation
so as to cause swelling and pain.

5. Too loose bandages which do not support the
wounded part, and arc allowing the dressings to slip.

6. Increasing pain, which may indicate h senior-

42 EARLY TREATMENT OF WAR WOUNDS

rhage in the depth or the onset of gas gangrene. In
either case, the patient should be expedited to the
casualty clearing station with a note drawing atten-
tion to his condition*

Operations at Aid Posts or Dressing Stations —It

is not advisable under the conditions of this war
to make elaborate arrangements for serious surgical
operations on patients within the zone of ordinary
shell fire. Therefore, as a routine, only such opera-
tions as are absolutely necessary should be per-
formed in units in front of the casualty clearing
stations. Operations for haemorrhage which t hreatens
life, and those for the removal of hopelessly smashed
limbs are the only ones which ought to be done, un-
less under very exceptional circumstances.

Amputations. — Hopelessly smashed limbs which
are tending to bleed, or which are hanging by mere
shreds of tissue, should be removed. Such limbs,
owing to their dragging on exposed nerves, may give
rise to great pain and an increase of shock. As a
rule the amputation, which the projectile has all but
accomplished, can be completed by a single sweep of
a sharp knife. A previous injection of morphia, to-
gether with the local shock-ansesthesia of the tissues
in the neighbourhood of the wound, will generally
permit of the operation being performed without the
use of a general anaesthetic* If necessary the still un-
divided skin may be anaesthetized by the injection of
a few syringefuls of \ per cent, novocain. Although
the dividing of the still sensitive tissues may inflict
momentary pain, if is found that in the long run
such eases do better if the use of a general anaesthetic

♦

WOUNDED MEN AT ADVANCED UNITS 43

has been avoided. As a rule, a ragged stump of this
nature bleeds very little, and what haemorrhage
there is ean usually be controlled by packing and
elevation. As a precaution, a tourniquet can be
laid loosely around the limb ready to tighten if neces-
sary, The patient should be retained for an hour, if
circumstances permit, in order to make certain that
haemorrhage has stopped.

If it is considered necessary to administer a general
anaesthetic, more attention should be paid during
the operation to the toilet of the stump, so that the
necessity of repeating the anaesthetic on arrival at
the casualty clearing station may be avoided. After
the use of a general anaesthetic it is usually advisable
to retain the patient for a period of twelve hours,
as otherwise such cases travel badly.

When pressure of work is so great or surgical
facilities so small that it is advisable to avoid the
performance of an operation even so trivial as that
of removing a shattered limb, an alternative pro-
cedure can be adopted to avoid the possibility of
further loss of blood from the torn tissues, A tight
tourniquet is applied just above the level of the in-
jury and the patient sent down with a special note
calling attention to his condition. On arrival at the
casualty clearing station the limb is amputated just
above the level of the tourniquet, clear of the tissues
that have suffered from the cutting off of their blood
supply. This method, although it overcomes the
risk from haemorrhage, does not confer on the patient
the boon of removing early a useless and painful limb.
Haemorrhage,— To ensure that haemorrhage has

44 EARLY TREATMENT OF WAR WOUNDS

been effectually controlled is the most important
item in the surgical treatment of the aid post and
the ambulance dressing station. As well as being
the most important it is often the most difficult, and
demands both judgment and promptness of action.
The haemorrhage that takes place rvhen a main artery
is divided is usually so rapid and so copious that the
wounded man dies before help can reach him. In
less severe cases profuse bleeding takes place for about
two minutes, and then, owing to the rapid fall of
blood pressure, haemorrhage tends to cease. At any
moment during the journey from the trenches an
artery that has been temporarily occluded by retrac-
tion and the formation of clot may start to bleed again,
and it is in these cases that prompt action may save
a life.

But apart from the danger of a fatal ending as a
direct result of haemorrhage, there always exists a
danger of death from the severe sepsis that almost
invariably follows the loss of a large amount of
blood from a lacerated wound. Shock, haemorrhage,
and sepsis go hand in hand, and; when bleeding
has been severe, virulent sepsis can be confidently
predicted. Therefore, to a severely wounded man,
the loss of every additional ounce of blocd is of
utmost importance.

Operations for Haemorrhage,— When an important
artery or vein has been divided in the depth of a
wound, the operation required in order that it may
be tied may present great difficulties. If, however,
the casualty clearing station is some distance away
and there is no alternative but that of despatching

WOUNDED MEN AT ADVANCED UNITS 45

the patient with a tourniquet that must of necessity
remain in position many hours, these difficulties must
be faced- In arriving at a decision as to whether
to operate or to trust to a tourniquet, it is worth
remembering that about 80 per cent, of limbs whose
blood supply has been cut off by a tourniquet for a
period of three hours or thereby eventually come to
amputation.

Once decided upon, the operation must be boldly
performed. The essentials are, a helpful assistant, a
good light, some strong silk, and a sharp knife. The
wound must be freely opened up so that the bleeding
point may be seen and easily tied. A second assist-
ant controls the tourniquet and relaxes or increases
pressure as may be required. Blind groping in the
dark in a haphazard attempt to seize something in
the grasp of a pressure forceps is useless, and gener-
ally results in the loss of much additional blood. Un-
less the operator feels confident to face the operation,
it is better to rely on a properly applied tourniquet.

Sometimes a ligature cannot be applied -easily to
a vessel which has been caught up by forceps. If
the wound is complicated or is a very deep one, the
patient should be sent on with the forceps in situ .
Arrangements must obviously be made for the im-
mediate return or exchange of tourniquet, forceps,
or other special appliances sent down in this way, so
that the field ambulances may not suffer from their
loss.

Very exceptionally the M.O. is confronted by a
case of profuse haemorrhage from a penetrating
wound in some region {such as the neck) where the

46 EARLY TREATMENT OF WAR WOUNDS

use of a tourniquet is out of the question. The
circumstances may he such that any attempt to
enlarge the wound and clamp the divided artery is
impossible, either on account of the delay entailed
in such a proceeding or on account of lack of surgical
facilities. If packing fails in such a case, the only
remedy that remains is to completely close the wound
by means of sutures embracing not only skin and
deep fascia, but also superficial muscles. By this
procedure the case is converted into one of diffuse
traumatic aneurysm, in the hope that after a certain
amount of bleeding has taken place into the deep
structures the extra-arterial pressure thus produced
will prevent further loss of blood.

When the bleeding is in the nature of a general
oozing from an extensive surface rather than of an
active haemorrhage from some definite vessel it can
usually be controlled by skilful packing. If the
wound is not an open one, but has a narrow orifice,
it must be laid open before the packing is applied.
The insertion of a cork of gauze into the orifice of a
wound that is bleeding from its depth is to be depre-
cated. In some cases haemorrhage is taking place
from a fairly well localized area of the wound, al-
though no vessel can be seen to which a ligature can
be applied. Here it is convenient to under-run the
area with a curved needle and tie off the enclosed
tissue. As a rule, it is preferable to use strong silk
in all these ligature operations, as the catgut in the
field panniers usually breaks.

A type of wound which, though possibly it may not
appear to be severe, is likely to give rise to serious

WOUNDED MEN AT ADVANCED UNITS 47

results, is one from which steady oozing occurs. The
medical officer, who first sees such a case, may have
applied compression and voluminous dressings in the
hope that the oozing may stop. The soaked dressings
are removed by the next medical officer who sees the
ease and who reasons in the same way* This may
occur even a third time, so that although at no time
is the bleeding at all alarming, the patient arrives
at the casualty clearing station in a collapsed
and anaemic condition, having lost in the aggregate a
large amount of blood. Wounds in the neighbour-
hood of the articulations, especially wounds of the
ankle, the knee, the shoulder, and the scapula are
particularly liable to act in this way. They should
be opened up in the manner described above, and the
bleeding, which is usually venous in origin, controlled
by packing. An antitoxin syringe containing a §
per cent, solution of novocain and a few drops of
adrenalin is an extremely useful weapon in such
operations. The distal side of a wound can often
be incised without pain.

After bleeding has been arrested, the limb should
be raised as high as possible, and the patient re-
tained a sufficient length of time to make certain
that the haemorrhage has completely stopped. If
any doubt still exists, a tourniquet should be laid
loosely round the limb and the patient evacuated
with a special orderly in charge. The tourniquet
may be tightened in ease of necessity.

It must always be remembered that any wound
of a limb in which bleeding has had to be specially
controlled must be splinted. Sudden movement

48 EARLY TREATMENT OF WAR WOUNDS

will often restart bleeding that has been only tern-
porarily checked.

Cases of diffuse traumatic aneurysm, in which the
rupture of an important vessel has been followed by
extensive bleeding into the tissues and great swelling
of the limb, should not be operated on in a field
ambulance. They should be well splinted and
despatched forthwith to the casualty clearing station,
accompanied by a special note. The finding of the
damaged vessel in such cases is always a difficult
task, and the fact that the distal circulation of the
limb is gravely imperilled calls for operation at the
earliest possible moment.

The Tourniquet. — -The application of a tourniquet
must always be considered a temporary measure, to
be followed as soon fts possible by the adoption of
proper methods for the control of haemorrhage. As
before stated, the retention of a tourniquet in posi-
tion for quite a short time is, in a large number of
cases, followed by amputation of the limb.

The elastic tourniquet is not an easy instrument
to use. It is remarkable how frequently it is applied
ineffectually. It must always be placed in position
with the j’ubber already on the stretch, and then
secured without any slackening having been allowed
to take place. This task will be rendered much
easier if a small triangle of strong wire, such as that
used for binding trusses of hay, be prepared for use
with the tourniquet. One angle of the triangle,
whose sides are about 4 inches in length, is hooked
over the anchor of the tourniquet and allows of it
being controlled without the fingers getting in the

WOUNDED MEN AT ADVANCED UNITS 49

way. It may similarly be used when it is required
to slacken the tourniquet. (See fig. 11.)

As already stated, if a tourniquet is applied in
order to control bleeding from a shattered limb whose
immediate removal is, for some reason or other, im-
possible at the time, it should be put on as low down
as possible. It will then be possible to save the
maximum amount of limb when the subsequent
operation is performed, just above the level of the

tourniquet. Whenever a patient is sent down with
a tourniquet in position its presence should be clearly
indicated on the tally.

Fractures, — No lesson has been more clearly
taught by the experience of this war than the neces-
sity for the efficient splinting of fractures at the
earliest possible moment after injury. Improvements
in the method of splinting compound fractures of the
femur, and the use of the Thomas’ splint at a point
much farther forward than was formerly considered
possible, have led to a reduction of the mortality
rate in cases of this nature of at least 30 per cent.

50 EARLY TREATMENT OF WAR WOUNDS

The principle applies equally well to injuries of other
bones, for, by early immobilization of the injured
parts, not only is the shock of the journey enormously
diminished, but also the further damaging of sur-
rounding tissues, by movement of the broken and
displaced fragments, is prevented.

General Remarks on Splinting —For transport pur-
poses those splints are to be preferred in which it
is possible to apply u self-contained extension,” as
is the case with the Thomas’ knee splint. The
simplest pattern of splints are the best, and they
should be capable of adjustment with the least pos-
sible disturbance of the patient. When fractures
are handled, a pull on the affected limb should
always be kept up, so that the fractured surfaces are
prevented from rubbing together unduly. It is
rarely necessary to administer general anaesthetics,
because the opposition of wounded muscles ean almost
always be overcome by slow and steady traction.

In order to provide greatest comfort for the patients
during transport the following three points must be
attended to :

(1) Adequate extension,

(2) Adequate support for the wounded part,

(3) Prevention of rotatory movements.

The minimum amount of bandaging must be done
so that easy readjustment of the splint is possible.
Tapes with buckles are often all that is necessary.
Long splints ought to be prevented from displace-
ment by fixing them to the skin, or possibly, as in
the case of fracture of the thigh, to the Thomas’
splint. A strap of adhesive plaster round the lower

WOUNDED MEN AT ADVANCED UNITS 51

and tipper extremities of a long straight splint will
usually be sufficient. The strip may encircle the
limb on the distal side of the wound, but proximal
to the wound it should be applied spirally or in an
incomplete circle and then not tightly. Care must

Fig. 12,

be taken that the proximal splint strap or turns of
bandage in no way constrict the limb,

A variety of splints must be provided for each
limb on account of the varying situation and the
size of the wound as well as the variation in site
and extent of the fracture.

Early amputations for fracture should be done

EARLY TREATMENT OF WAR WOUNDS

only when vessels and nerves are also destroyed, or
if extensive gangrene of the part of the limb distal
to the fracture has occurred. As a general rule mere
smashing of bone, even with severe laceration of
muscle only, is not sufficient justification for early
amputation. A combination of circumstances may

A, Jones' extension humerus

splint.

B. Applied for fracture of left

humerus.

Fig-. 13.

arise which compels interference of this sort in an
ambulance dressing station, e*g. the general condition
of the patient, his inability to bear further transport,
the distance of the casualty clearing station, and
the virulence of the infection.

Whenever possible , ike splint should be applied and
extension made before dressing or other handling of the
wound is carried out

WOUNDED MEN AT ADVANCED UNITS 53

Fractures of the Humerus.- -The splints and their
method of application shown in the sketches are
those which have been found to be the most valuable.

For fractures involving the shoulder joint, or when
a wound in that neighbourhood prevents the applica-
tion of any “ crutch ” splint, the use of a triangular

54 EARLY TREATMENT OF WAR WOUNDS

axillary pad, base downwards, a clove-hitch round

the wrist to act as a sling,
and a many-tailed or tri-
angular bandage to fix the
arm and forearm on the
el iest 5 will enable the pa-
tient to travel in comfort*
In some cases a piece of
Gooch’s splinting along
the outer side of the arm
is advisable. If a many-
tailed bandage is used,
each layer should be fixed
by a safety-pin. If the
patient can sit upright, a
broad roller bandage may
be used and fixed in the
same way.

For fractures of the
shaft. Depage’s modified
splint is practically always
applicable. (The curve of
the fore-arm piece of this
splint usually requires to
be “ flattened,” The swi-
vel joints should be made
to move freely before use.)
Jones’s extension humer-
us splint has also been
used fairly frequently, but
is not very convenient for aid post work. For frac-
tures at or near the elbow, whether of forearm bones

Thomas' arm splint (bent
near ring), applied
for low fracture of
left humerus,

Fick 14a.

WOUNDED MEN AT

or humerus, the small Thomas 5 splint is the best. If
the small Thomas’ splint be used, an anterior and
posterior splint, well padded, should be added for
support. For transport on a stretcher this splint is
bent (over the edge of a table or stretcher handle), or

Extempore Aluminium or
strong wire splint for
fracture of humerus.
Applied for fracture of
left humerus.

is provided with a swivel one inch below the ring* A
very efficient splint can be made rapidly by bending a
strip of “ strap ” aluminium or thick Wire in the way
shown in the sketch ; the crutches must be turned
at right angles to each other, according to the side
for which it is used*

56 EARLY TREATMENT OF WAR WOUNDS

These cases do not require a great deal of exten-
sion force in order to make them comfortable. One
must remember that, in applying such a splint as

Fiq * 16.

A => Tflpsou*s sola dip. ♦

B Sole clip applied,

0 = Thomas' knee splint.

Depage modified,” the long forearm furnishes a
very powerful lever. When the small Thomas’ splint
is used, too strong extension by a bandage round the

WOUNDED MEN AT ADVANCED UNITS 57

wrist may result in gangrene of the fingers or
hand.

Short anterior thigh piece The corners (a) for
right and (b) for left thigh, should be cut
away.

A

A, Gooch's splinting, 26" X 5 ",
Wooden “ Ham " splint.

Fig. 17.

Fractures of the Femur,- The use of Thomas' splint
outfit for fractures of the thigh or leg bones,

Thomas 5 splint outfit consists of :

( 1 ) Thomas’ knee splint.

58 EARLY TREATMENT OF WAR WOUNDS

(2) A posterior supporting splint. (Gooch’s splint-
ing, a wooden “ Ham ” splint, or Jones’s metal
fracture or gutter splint.)

(8) A short anterior splint for the thigh.

(4) A strong wire footpiece for preventing wobbling
of the foot.

(5) Two stretcher suspension bars.

(0) 1-in. adhesive strapping and bandages or splint
tapes.

(7) A Tapson’s heel clip.

This has proved to be the best method of prevent-
ing shock and should be used as soon as and whenever
possible . The only occasion on which the use of the
Thomas’ splint is impossible is when the site of the
wound corresponds with the back or inner part of
the ring of the splint ; that is, if a wound of the

8

A. Foot piece— strong wire
B , Stretcher suspension bar.

Fig. is.

WOUNDED MEN AT ADVANCED UNITS 50

lower part of the buttock or perineum exists. A
wound of the groin or trochanteric region need not
prevent its use. No other splint or no modification
of Thomas 3 splint has been so successful in bringing
these patients in good condition to the casualty
clearing stations. Patients with compound fracture
of the femur bear handling particularly badly.
Liston’s long splint has been favoured by some.
Only very rarely indeed do eases treated in this
splint arrive without severe shock. One need not
detail the reasons. During a severe battle in the
spring of 1017 the mortality of cases of fracture of
the femur at casualty clearing stations v f as reduced
by at least 30 per cent., even though the comparison
was made with the results obtained during previous
“ peace ” times. At this battle period practically
every ease w'as sent down in Thomas’ splints, whereas
in the peace period Liston’s and other splints were
used as well. The death rate from gunshot fracture
of the thigh was at one time of the war about 80
per cent., and nearly 50 per cent, occurred at casualty
clearing stations. The death rate at the casualty
clearing stations during this battle was 15fi per cent,
in 1 ,000 cases. Previous to the battle the method of
application of the splint w as widely demonstrated.
Before this, these patients used to arrive in such a
shocked condition that they could not be touched for
hours. Only 5 per cent, of the cases admitted dur-
ing this battle were unfit to be operated on immedi-
ately after admission. This was owing chiefly to the
presence of severe wounds elsewhere, or to the fact
that, the patients having been lying out, the wounds

60 EARLY TREATMENT OF WAR WOUNDS

ft

were already in a hopeless state of sepsis* Certain
surgeons had, previous to this time, been expressing
the opinion that more lives would be saved if ampu-
tation were done in every case of fracture of the
femur, yet the number of amputations in this series
was only 17*2 per cent. It is therefore evident that
more conservative measures were possible than ever
before.

The fact that such patients bear handling ex-
tremely badly lias led to the general adoption of the

plan of putting on the Thomas’ splint without re-
moving either trousers or boots. The application of
the splint will be gathered from a study of the ac-
companying drawing. An orderly lifts and steadies
the limb, making extension all the time;* the trousers
opposite the wound are cut open freely; the wound
is attended to, and covered temporarily ; the splint
is applied and extension made with a Tapson’s sole
clip or a calico bandage or puttee clove-hitch ; a
pad should be put round the ankle and over the dorsum
of the foot if a clove-hitch or other knot is used ; the
limb is supported behind by the hand of an orderly

WOUNDED MEN AT ADVANCED HUTS 61

(after extension is applied, a bandage sling in the neigh-
bourhood of the knee may be used instead, while
the orderly holds up of manipulates the end of the
splint) ; the wound is dressed and the supporting
posterior splint, well padded so as to flex the knee
slightly and support the femur well, is then slung to
the side bars of the Thomas’ by sticking plaster*
An axiterior short thigh splint prevents flexion of the
upper fragment and gives greater security. The foot-
piece is finally fixed in position and prevents u wob-
bling ” of the foot better than anything else. If
the boot has been removed the foot must be well
padded before the foot-piece is applied. If the boot
has been removed on account of wounds of the loot,
extension may have to be made by ordinary adhe-
sive plaster strips applied to the leg above the
wounds ; but, when possible, all things considered, a
clove-hitch around the thickly padded ankle, with
knot on the outer side, is most suitable.

A long posterior supporting splint is better than
interrupted slings.

When extension is made, clot may be dislodged
from the lumen of thfc main artery. As already re-
marked, death has occurred, in patients previous
exsanguine, from this cause. Therefore, in order to
get at the wound easily, no encircling bandage should
be put around the dressing before extension is made,
and the necessity for immediate digital compression
of the femoral should be borne in mind.

The extension should be examined at every stop
ping place and adjusted if necessary. While an
efficient pull is of the greatest importance, it must be

C‘2 EARLY TREATMENT OF WAR WOUNDS

remembered that gangrene of the skin and even of
the foot has been caused by too strong and improperly
applied extension.

The splint should be slung, by two pieces of band-
age, from the suspension bar so that the foot just
swings clear of the stretcher. If a suspension bar is
not available these bandages may be tied to the
traverse of the upper bunk in the ambulance car.
The patient’s pelvis may be steadied by a broad
bandage .encircling both pelvis and stretcher, but the
splint should be allowed to swing freely, otherwise
unnecessary jarring occurs. The plan, suggested
recently, of suspending the ring or upper end of the
Thomas’ splint lightly from a second suspension bar
prevents slipping of the ring and provides extra com-
fort during transport. Careful attention to fixing of
blankets must be given when it is used.

Unless there is a distinct indication for changing the
dressings of these cases during transport, they should
not be interfered with, except to control extension
and suspension of the limb and fixation of the foot.

Patients who arrive at casualty clearing stations
without these points being attended to are always
in worse condition than those who have been pro-
perly looked after.

If the suspension bars and footpiece are not avail-
able at very advanced posts, the projecting end of
the Thomas’ splint should be supported on, for
example, an empty petrol tin or brick laid on its
side, so as to carry the heel free from the stretcher,
and the foot should be fixed by a figure of eight
bandage. The reversed wire footpiece is too narrow

WOUNDED MEN AT ADVANCED UNITS 63

to form a good support, even when it is available.
When it is used in this way the splint and limb in-
variably become twisted.

If a supporting back splint is not available, the
leg of the trousers should be out down in front and
pinned firmly over each side bar of the Thomas’
splint.

When a patient is picked up on the field, the follow-
ing device will be found serviceable. A puttee or
strong bandage is passed under the perineum and
round the “head ” handle of the stretcher on the side
opposite to the injury, pulled and tied firmly. A
clove-hitch is fixed over the ankle and strong exten-
sion is made round the foot handle on the same side
as the injury. Two or more splints are fixed on the
thigh by two strips of bandage or splint tapes. The
foot is kept from rotating by the support of bricks,
equipment, etc., or the toe of the boot is connected
by bandage or puttee to each foot handle. The pelvis
should be bandaged to the stretcher.

One of the best methods of procuring extension
is by the use of Tapson’s sole clip. The clip is made
from thick iron wire. (See diagram.) The prongs of
the clip should be slipped into the groove between
the sole and the “ upper of the boot immediately
in front of the heel. “Splint tapes” may be used
for making extension, as shown in the diagram, but
a strong bandage, which is passed through the ring
of the clip and over the notch of the splint twice, will
prove more reliable and equally easily manipulated.

Removal of the boot is justifiable only when a
wound of the foot makes it necessary or when the

64 EARLY TREATMENT OF WAR WOUNDS

boot and sock are wet and trench foot is suspected.
See previous remarks under “ Removal of Wet Cloth-
ing” (page IT).

Fractures of Leg Bones* — For those in the upper
two-thirds of the leg Thomas’ splint as applied for
fracture of the thigh is the most suitable. For those
near the ankle a long back splint with foot-picce
(Barbour) plus two lateral straight splints, which
should bear both on the footpiece and on the back
splint, should be applied. Owing to its tendency
to fall over on its side during transit and cause
twisting of the limb, the splint should be anchored
to the stretcher by bandage “ stays ” passing from
the top of the foot-piece to the stretcher runners on
each side.

Wounds of Joints, especially Knee Joints*— All

penetrating wounds should be splinted* In the case
of the knee, if the wounds are not accompanied by
fracture, a straight gutter splint, well padded to pro-
duce slight flexion, reaching from the tuber ischii to
the heel, is sufficient* More serious wounds, with
fracture, should be put up in a Thomas 5 splint
outfit.

Head Wounds,— The scalp around the wound
should be well soaked with picric acid solution. In
gutter wounds, any gross dirt, projecting bone, or
foreign body should be removed and a piece of im-
pregnated gauze placed to keep the wound open.
In a puncture wound no attempt should be made to
disinfect the track. In no ease should the brain
be interfered with, except to remove any visible
loose bone or foreign body which during transport

WOUNDED MEN AT ADVANCED UNITS 65

might cause further damage. Direct pressure by
dressings over a hole in the skull should be avoided,
as it may cause cerebral compression to occur.
Rather make a “ bank ” of folded gauze on each side
of, or all round, the wound, so that blood or disinte-
grated brain can readily escape. Head cases should
be propped up when possible. If not, a soft pillow
should be placed under the head, and sandbags,
pillows, etc,, placed at each side to prevent lateral
movements during lurches of the car.

Chest Cases- — In view of the success which has
attended radical operations, severe chest eases should
be sent to the casualty clearing stations as soon as
possible. Although not so urgent as abdominal
cases, yet delay imperils the success of the operation.
Cases with open u sucking wounds and severe
intrapleural haemorrhage may be so collapsed or
distressed that they cannot be sent on at once. The
closure of an open “ sucking ” wound brings about
very rapid relief and should be done immediately.
This closure is best done by suture (local anaesthetics
if necessary) or by u corking** the wound with gauze
plug, which is prevented from slipping by strips of
broad adhesive plaster. The strips should extend to
just over half the circumference of the chest. Con-
siderable amount of risk must be taken in sending on
many of these cases. The worse the wound the sooner
will the patient die if the chest cannot be closed.
If suture of a ^ sucking ?s wound is made, a note
should always be sent with the patient stating that
an open wound of the pleural cavity was present and
that the patient requires immediate attention.

66 EARLY TREATMENT OF WAR WOUNDS

Abdominal Cases, — These should be sent on at
once to casualty clearing stations unless it is obvious
that the patient is dying from shock or haemorrhage.
It must continuously be borne in mind that wounds
of the chest, especially of the lower posterior parts,
and wounds of the loins, buttocks, perineum, or even
upper part of the thigh, are frequently associated with
penetration of the abdominal cavity. In arriving at
a diagnosis it should be remembered that rigidity
and absence of free movement are of much greater
importance from a negative than a positive point of
view. Their absence precludes visceral injury, whilst
their presence may be due to other causes such as
chest wounds, retroperitoneal hsematomata, or in-
jury of the abdominal wall alone. Tenderness is
more conclusive than pain. Its presence at some
distance from the wound, especially when on the
opposite side, is almost diagnostic of visceral injury.
In cases of doubt always treat as if penetration had
occurred.

Multiple Wounds*— These are apt to be associated
with very severe shock. All possible care, therefore,
should be taken to prevent or assuage it. The
patient should be handled as little as possible. It
is often preferable to leave such cases absolutely
alone for a few hours, simply seeing that they are
kept warm* Sedatives may be given if the patient
is in pain*

Notes on Field Medical Cards * — Nature and severity
of wounds* Time of wounding*

Presence of shock and severity of haemorrhage.
Dose and time of giving morphia, etc.

WOUNDED MEN AT ADVANCED UNITS 67

Amount of antitetanic scrum injected,

A very short description of any operation or
special treatment carried out. (If foreign bodies or
fragments of bone have been removed , this should be
stated ,)

In periods of great stress time will be saved, in the
aggregate, by having a special orderly detailed to
make notes in the dressing room.

A note to the casualty clearing station should
accompany the car, with the names and number of
splints, instruments, etc., which are sent from dress-
ing stations, in order to facilitate immediate return
or exchange.

The Field Medical Card is meant to provide a con-
secutive record of the patient’s condition and treat-
ment in his passage through the field ambulance,
casualty clearing station, and hospitals on the lines
of communication.

CHAPTER II

WORK AT A CASUALTY CLEARING STATION

In this description, the conditions which prevail dur-
ing severe fighting are dealt with. During quiet
times the work of the unit should be conducted on
identical lines, so that in the active periods simply
a speeding up or augmentation takes place.

As in more advanced units, so also in casualty
clearing stations, professional instincts and desires
cannot be satisfied as one would wish, owing to
many considerations connected with the military
situation. It has become generally accepted, how-
ever, that the casualty clearing station is the “ site
of election for operations on men wounded at the
front. Only operations of extreme urgency, such
as for the control of severe haemorrhage, should be
undertaken at stations farther forward, owing to the
impossibility of providing the necessary equipment*

The value of pre-inflammatory operations and there-
fore the importance of the surgical work at casualty
clearing stations cannot be over-estimated* The
amount which has to be done during severe fighting
is sometimes very great and can only be gauged
approximately beforehand* The quality of the work is
more controllable. The most skilful and experienced

AT A CASUALTY CLEARING STATION 69

surgeons should be available in sufficient numbers
to cope efficiently witli the probable amount of work.
Operations which are done must be thorough. Timid
half measures too often prove valueless in saving life
or limb, or result in repeated later operations which
can usually be prevented by more radical treatment
in the first instance. Radical conservative measures
are being attended with increasing success. Experi-
ence has shown to many operators that limbs can
now be saved which previously would have been
sacrificed. Modern methods of resuscitation in cases
of profound shock, together with subsequent opera-
tion, snatch many patients from what looks like
certain death. In view of these considerations,
the casualty clearing station is, without doubt, the
hospital unit which, surgically, is of the greatest
value to the nation from both a military and civil
point of view.

It is necessary, therefore, that casualty clearing
stations should be equipped with every facility for
carrying out surgical work rapidly and efficiently.
All possible aids to diagnosis and treatment such as
arc furnished, for example, by up-to-date X-ray and
bacteriological laboratories must be included. At
the same time the mobility of these units must be
kept constantly in mind.

The surgical and nursing staffs must be of the
best. Theatre accommodation and equipment must
be ample and adequate to deal with any emergency.
Special pre-operative and post-operative wards, for
various purposes, must be provided. The organiza-
tion must be perfect in every department, so that

70 EARLY TREATMENT OF WAR WOUNDS

patients may be received, housed, warmed, fed,
transported, and otherwise attended to within the
hospital without a hitch. It is obvious, further,
that special arrangements for rapid evacuation
of patients must prevail. Only such patients as
will suffer unduly from further immediate transport
can be retained. Put briefly, the functions of a
casualty clearing station during a “ push ,s are to
save life, limb, and function where possible and,
generally speaking, to fortify all patients against the
effects of further early transport. It must also
eliminate and dispose of very slightly wounded men
to selected hospitals or rest stations in the neigh-
bourhood. Such patients should be retained as near
the fighting line as circumstances permit. They are
usually fit for duty in a very short time.

Casualty clearing stations must be outside the
range of ordinary shell fire, but at the same time be
as far forward as the military situation will allow.
Apart from the consideration of a probable casualty
list, the mental effect on the helpless wounded man
of shells bursting in the neighbourhood, or even of the
noise of friendly guns, cannot be disregarded. The
group of hospitals must be placed at a point where
roads from the front, passable for ambulance cars,
converge, where easy evacuation by ambulance train
is possible, and where there is a good water supply.
A special hospital siding from the railway line is
essential in order to reduce interference with other
traffic to a minimum. Other military considerations
may prevent selection of what seems the best site.
Suitable buildings are now rarely available. The

AT A CASUALTY CLEARING STATION 71

hospitals have usually to be pitched in the open.
The best site for easiest working is on the side of a
smooth, gentle slope, at the top of which runs the
main road from the front and at the bottom the
hospital siding, A system of light railways, as the
Decauville, should be provided within the hospital.
It is easily appreciated that all these and many
other matters have a great influence on the surgical
condition of patients as well as on the question of
administration.

The importance of warmth to a wounded man has
already been emphasized. During cold weather,
under the conditions of campaign which exist on the
greater part of the front in France, the problem of
furnishing and conserving beat is a most difficult one.
The casualty clearing station is looked upon by the
wounded man as his first real haven of rest, and that
haven must be warm, else it loses much of its physical
and mental benefit. No detail should be neglected
which will protect the man from cold on a stormy
winter day. The temperature of the reception room,
evacuation shelter, and other parts of the casualty
clearing station is only of less importance than that of
the operating theatre. Cold is one of the greatest
factors in maintaining or aggravating the condition
of surgical shock produced by a serious wound on a
man already predisposed to it by enormous physical
and psychical strain. The badly wounded man should
be under cover and protected from cold from the time
he is unloaded from the heated ambulance car until
he is evacuated to the base.

Rest is of equal importance. Efficient splinting

72 EARLY TREATMENT OF WAR WOUNDS

and careful handling and driving minimize the evil
effects of transport over rough roads* In the casualty
clearing station itself all arrangements should provide
that patients are moved or disturbed as little as possible
until they have recovered from the journey and are
fit to undergo the surgical treatment which they so
urgently require. The less seriously wounded man
benefits, comparatively speaking, as much from these
arrangements as does his less fortunate comrade.

The usual plan of dealing with patients cannot be
discussed in detail* Casualty clearing stations arc
usually arranged in groups of two to four, and patients
are received by each in turn, in numbers previously
agreed upon* Two sitting cases are looked upon
as equivalent to one lying ease. The object of this
arrangement is to assign to each unit cases sufficient
for it to deal with satisfactorily before the next batch
comes along. It is doubtful if it is desirable to set
apart any casualty clearing stations to deal with
walking wounded alone.

Efficient organization of stretcher bearers and other
methods of transport in the casualty clearing station
is of immense value in the smooth and rapid working
of all departments of the unit*

Ambulance cars drive along a switch from the
main road to the reception room door, where patients
are unloaded. W aiting cars should not be opened
up until their turn for unloading has arrived. A
large porch on the reception room is advisable, with
wide doors on its three sides. Only the door on the
lee side should be used on a windy day. Unloading
should be done under cover when possible. The

AT A CASUALTY CLEARING STATION 73

reception room must be large so that convoys of cars
can deposit their burdens and depart without delay,
having been supplied with stretchers, blankets, splints,
hot water bottles, etc., in exchange for those brought
down with the patients. These are handed over
from a store situated farther along the switch. Great
care should be taken that the blankets are thoroughly
dry. Very simple structures, wooden frames covered
with blankets and heated by a suitable stove, have
been invented for warming and drying blankets, A
large one should be available for general supply, arid
smaller ones for every “ special ” ward.

In the reception room, the patients’ names and
other particulars arc entered in the admission and dis-
charge book, equipment disposed of, clothing searched
for ammunition, valuables put in a bag which accom-
panies the patient wherever he goes, etc. Fluid
nourishment should always be on tap. Hot tea with
plenty of sugar in it is most favoured by British
soldiers.

The patients are then taken to the dressing room
where thorough examination and decision as to their
further disposal are made. On this account the
medical officers detailed for this duty should, if pos-
sible, be men of very sound judgment and wide
experience in base as well as casualty clearing station
work. The officers in charge of the dressing-room
are, in fact, the most important in the casualty clearing
station, from a professional point of view. Enough
stretcher tables to cope with the work should be
available. One medical officer can supervise four
to eight tables, provided that one good nurse or

74 EARLY TREATMENT OF WAR WOUNDS

orderly is detailed for each table. Another medical
officer should deal with walking cases* if these have
not been diverted to a special casualty clearing
station. It is preferable to deal with walkers in a
separate dressing room. Severely shocked cases
should not be handled at this period, unless they
show signs of active external hemorrhage. Cases of
fractured thigh should not be “taken down” until
they arc anaesthetized on the operating table. In
both instances, however* pain or discomfort should
be allayed by suitable remedies.

Cases for immediate evacuation include all cases
which do not require operation, with the exception of
most penetrating chest wounds — with hemothorax,
and cases which are suffering from such exhaustion
and shock that their condition would still further be
jeopardized by a railway journey. Wounds which *
do not require operation should be carefully dressed.

In all other cases it must be remembered that un-
necessary handling is very detrimental. If clear
notes from a field ambulance officer accompany the
patients it may be unnecessary to look at their
wounds till they arc on the operating table. If it is
necessary to overhaul and redress wounds, a note
should be made of the nature and number of wounds*
and which arc the most severe* for the guidance of
those dealing with the eases afterwards. For this
purpose a special note clerk will be of great assist-
ance. Dressings, of eases for operation, should be
fixed in as simple a way as possible.

Light cases for operation are sent to a light pre-
operative ward, where they arc prepared. Very wet

AT A CASUALTY CLEARING STATION 75

clothing should be changed, but otherwise it is un-
necessary to undress them more than will expose
their wounds thoroughly and prevent clothing from
being soiled at operation. In turn, they go to a light
operating theatre, light recovery ward, where they are
retained until they have recovered from the effects
of general anaesthesia, and finally to the evacuation
shelter.

Hot drinks for the more severely wounded and
more ordinary food for the very slightly wounded
must lie provided.

Severe cases for operation are distributed to different
wards according to the nature of ulieir wounds and
their general condition, en route for /the severe opera-
tion theatre. / The bulk of these cafces arc sent direct
to the severe pre-operatimk ward. Here they are un-
dressed, washed my^pit into warm appropriate
clothing, They] are 'warrpc^-% various means and
given hot nourishing drinks if they-ftavS toVau long

for operation. Their wounds should not be interfered, „

with if definite information regarding these has been
sent from the dressing room. Otherwise, except in
cases of fractured femur, an attempt should be made
to estimate the comparative severity of wounds for
the guidance of the operators in the theatre. The
hair may be softened by soap dressing in head cases,
if time does not permit of complete shaving or removal
by depilatory paste. The medical officer in charge
arranges the order in which cases are to be taken to
the theatre.

The resuscitation ward, to which very bad eases
arc sent, is equipped with all necessary appliances

76 EARLY TREATMENT OF WAR WOUNDS

and other remedies for restoring animation. Many
suffer from such severe shock that they have liter-
ally to be coaxed back to a condition of reasonable
vitality. Warmth, absolute rest, sedatives, and
transfusions of various kinds arc the chief successful
remedies. The sisters in charge should be most
carefully selected. It is wonderful the amount of
success which is achieved by some compared with
others. A “ shock team,” medical officer and
assistant, also specially selected, superintends the
administration of blood transfusions, etc., and looks
after the worst cases. They may be required from
time to time in the operation theatre for similar
work.

Men with severe penetrating chest and abdominal
wounds should be sent to a special preoperation ward
for special observation and treatment. In 20 to 30
per cent, of chest eases and in over 90 per cent, of
abdominal cases, operation is the only treatment
which will save life, and that only if it can be
carried out early.

It goes without saying, that skilful treatment in
these pre-operative departments will save many
lives, and that an adequate number of trained
attendants must be allotted to them. At the same
time, one cannot refrain from remarking that too
much attention is almost as bad as too little.
Well-organized, precise arrangements ensure rapid
and successful treatment. This applies as much
to duties like stretcher-bearing as to the most
scientific procedures, A full supply of warm, dry
blankets and of hot water bottles must be available.

AT A CASUALTY CLEARING STATION 77

It must be remembered that military exigencies
will not admit of extravagant arrangements in opera-
tion theatres. With skilful surgeons, anaesthetists,
and attendants, it is found that results are equally
good whether operations are performed in separate
small theatres or in one large theatre common to alL
The latter is therefore, under the circumstances, pre-
ferable. The size of the hut usually provided ac-
commodates six tables easily. Everything inside the
theatre should be arranged to allow the freest possible
movement of stretcher bearers, without interfering
with other work. Arrangements for washing and
disinfection of hands, instruments, dressings, etc.,
and disposal of sterilizing, splint, and other rooms
depend on local idiosyncrasies of men and locations,
and Bleed not be discussed. Easy communication
with the X-ray department is essential. The
problem of warming the theatre is one which requires
most careful attention. The dispensary, or drug-
store, and reserve of splints should be within easy
reach of the operating theatres.

Patients who undergo severe operations are kept
for a varying period in post-operation wards. Segrega-
tion of different types of wounds in special wards is
frequently made.

A large hut, or enough marquees roped together
to make adequate accommodation, should be pro-
vided at or near the railway siding. Walking cases
are kept in one part, stretcher cases in another. As
already indicated, warmth is of as much importance
here as elsewhere, especially if walking eases have to
be sent off in an indicated iniprovized ambulance train*

78 EARLY TREATMENT OF WAR WOUNDS

It has been found that the detailing of surgical
teams, the members of which have worked together
and know each others’ capacity, has resulted in marked
improvement both in the quality and quantity of the
work done. A team consists of a surgeon, an anaes-
thetist, a nursing sister, and an orderly. The number
of teams and the number of other attendants must
vary according to the estimated amount of work to be
done. One or two tables more than those actually in use
by the surgical teams working in the theatre should
be kept for patients next for operation. An extra
anaesthetist, sister, and orderly attend to their pre-
paration. When slightly wounded cases are being
dealt with, two or more tables are allocated to each
team. Such an arrangement conserves time.

The work of the casualty clearing station should
be judged from the condition in which its patients
arrive at the base more than by the number of cases
which it passes through, although in times of high-
est pressure the latter function becomes of equal if
not of paramount importance. On some occasions,
indeed, the casualty clearing station has to be trans-
formed into a glorified dressing station. Operations,
unless most urgent and at the same time most hopeful,
are given up for the time being. At all times the aim
must be the greatest good to the greatest number.
Experience alone teaches how that can best be at-
tained, Many patients who obviously require early
operation may have to be passed on or left until the
excessive numbers have been dealt with.

In conclusion, one feels compelled to say, with
regard to the surgical operations which have to be

AT A CASUALTY CLEARING STATION 79

performed, that the surgeon fresh from civil practice
will have many failures unless he at once models his
work on the lines which bitter experience has taught
to others. He will speedily find that war wounds in
France behave very differently from those to which
he is accustomed at home, unless they arc treated
efficiently on certain definite principles. If these
principles are appreciated, common sense and good
technique in their application will ensure at once a
great measure of success.

CHAPTER III

The nature of wound shock and the best methods
of combatting it are amongst the most difficult
questions that confront the military surgeon. They
arc problems that trouble the regimental medical
officer, the ambulance officer, and the surgeon at the
casualty clearing station with equal insistency, and
the greater the progress that is made in other direc-
tions, the more does “ shock ” stand out as the great
unsolved riddle of military surgery.

During the last two years great efforts have been
made to throw more light on the subject of wound
shock, by means of laboratory investigations at
home and by clinical observations abroad. It is
not proposed in the present chapter to deal with the
physiological aspects of this research, but rather to
epitomize the work that has been done in France,
and particularly that portion of the work that has
been carried on in the army to which the writers
happened to belong (see Preface). For those who
desire information on the physiological or experi-
mental side of the problem of shock the excellent
reports, published from time to time by the Medical
Research Committee, are strongly to be recommended.

80

TREATMENT OF WOUND SHOCK

81

The Nature of Wound Shock* — An enquiry into the
nature of wound shock is obviously an exceedingly
difficult one* The condition of the badly wounded
man is often due to the action of so many different
factors* and is complicated by the presence of so many
different conditions (e*g. shell concussion, haemor-
rhage* poisoning by gas, toxic absorption* etc.*) that
it is often a matter of great difficulty to unravel
the tangle and arrive at a just conclusion. More-
over, in dealing with this subject, it is necessary to dis-
tinguish between two conditions, namely, Primary
Shock, or the collapse immediately supervening on
the infliction of a severe wound, and Secondary
Shock , which develops later as the result of such
factors as exposure to cold, pain, haemorrhage,
movement, anxiety* exhaustion* and all the other
harmful influences associated with a long journey
to the casualty clearing station* Although most
observers are agreed on the existence of these two
categories, they are by no means in agreement as to
the frequency with which the condition of primary
shock is met* However, as it is with the manifesta-
tions of secondary shock that this chapter is chiefly con-
cerned* discrepancies of opinion as to the nature and
frequency of primary shock are of minor importance.
Factors influencing the Development of Secondary
Wound Shock* — Although the development of marked
secondary shock generally means that the original
injury is a severe one, or has been associated with
severe haemorrhage, this is by no means invariably
the case* In some instances the secondary exhaustion
is quite out of proportion to the severity of the wound
0

82 EARLY TREATMENT OF WAR WOUNDS

or the amount of the haemorrhage* Many instances
have been known of badly wounded men reaching the
casualty clearing station in good condition, and
conversely of comparatively lightly injured men
developing severe secondary shock as the result of
their exhausting experiences subsequent to injury.
Different individuals vary widely in their capacity to
withstand shock, as also do battalions recruited from
different sources, or from different races* Indian
troops and battalions drawn from large towns, for
example, show a greater tendency to develop shock
than troops recruited from purely agricultural districts*
Officers, moreover, are more prone to shock than men,
especially when the period preceding their wounding
has been one of great mental anxiety, aggravated
by fatigue and lack of sleep. For this same reason
.“self-inflicted wounds” are frequently accompanied
by marked shock* The mental condition and general
state of health previous to wounding has thus an
undoubted influence on the development of secondary
wound shock*

Haemorrhage and Shock. — Haemorrhage is so con-
stantly associated with shock, and plays such an im-
portant part in its production, that the great majority
of cases are examples of shock-haemorrhage rather
than of pure shock. Unfortunately, it is extremely
difficult to estimate, even approximately, the amount
of blood lost by any particular patient during the
first few hours after wounding, but the total quan-
tity is probably greater than is generally supposed*
Captain O* II* Robertson, Med* Corps, U*S*A., has
shown that a secondary haemorrhage of even moderate

TREATMENT OF WOUND SHOCK

83

severity is followed by a very large drop in the total
blood volume. This drop, in the case of a severe
haemorrhage, may amount to as much as 50 per cent,
of the normal blood volume. A similar loss of cir-
culating fluid in normal people, and in favourable
circumstances, is rapidly replaced, but unfortunately
such is not the ease under conditions of war. For
some reason, hitherto undiscovered, the normal
mechanism which regulates the volume of the circu-
lating blood is upset in the case of the badly
wounded and shocked soldier.

The practical deduction that should be drawn from
this observation is that every effort should be made
at the earliest opportunity to replenish the depleted
fluid reserves of the wounded soldier by the adminis-
tration of large amounts of fluid, preferably through
the medium of the alimentary canal, per oram or per
rectum . It must be borne in mind that at all times
the supply of drinking water in the front line is very
limited in amount, and that the fluid reserves of the
unwounded soldier are in any ease likely to be below
normal. When called upon to make good the enor-
mous amount of fluid lost from the haemorrhage and
from the profuse perspiration that may follow the in-
fliction of a wound, these fluid reserves, already at a
low level, are rapidly exhausted. lienee the urgency
of replenishing them as early as possible.

Cold, — The importance of cold, in precipitating and
in aggravating secondary shock, has been pointed out
by all clinical observers engaged in this investigation.
Laboratory experiment has confirmed these views,
and has shown that cold contributes to the develop-

84 EARLY TREATMENT OF WAR WOUNDS

ment of acidosis and is a potent factor in aggravating
the circulatory disturbances present in shock. Clinical
observation and laboratory experiment aie thus
entirely in agreement on this point.

The importance of cold as a shock-factor having
once been realized by those working on the problem,
an energetic crusade in favour of warmth was carried
on amongst the personnel of the forward medical
units in France during the spring of 1017. Special
attention was paid to the protection of the wounded
man from the action of cold during the earlier stages
of his journey, and the use of the hot-air cooker,
described on page 21, was advocated and widely
adopted, A more extensive use of blankets, mackin-
tosh sheets, hot~water bottles, etc,, was urged, and
efforts were instituted to ensure better warming of
dressing stations, railway trucks, and ambulances.
The beneficial results of this crusade were clearly
indicated during the winter of 1917-18, Not only
did the incidence of secondary shock appear to be
diminished by these warmth measures, but the period
of resuscitation required in the case of those who
arrived shocked at the casualty clearing station was
materially curtailed. Earlier operation was thereby
achieved, and the danger of sepsis diminished.
Simultaneously with the improvement in the anti-
cold measures of the forward units, there were insti-
tuted various improvements at the casualty clearing
stations. The resuscitation ward became a recog-
nized feature of the latter unit. In this well-warmed
ward the badly shocked man received all the con-
centrated attention and care that his condition dc-

r\

TREATMENT OF WOUND SHOCK

85

manded at the hands of a sister and orderlies specially
experienced in such work, acting under the instruc-
tions of a specially experienced medical officer. By
these means many badly wounded men in need of
special attention and care were undoubtedly saved,
and much valuable knowledge gained. The specially
trained u shock team ” was initiated.

Compound Fractures and Shock*— It has always been
recognized that cases of severe compound fracture
arc especially prone to develop secondary shock during
the course of their journey to the casualty clearing
station. This is due not only to the fact that such
injuries are usually associated with profuse heemor-
rhage and severe pain, but, in the light of recent
laboratory findings, is also probably due in part to the
absorption into the general circulation of various toxic
products from the damaged limb. It lias been shown
experimentally that if the blood from damaged muscle
tissue be allowed to enter the circulation by removal
of a tourniquet, the entry is followed by a general
fall of blood pressure. This experimental finding is
not without its bearing on the question of treatment.
The extent to which fat embolism may play a part in
some cases is not clear.

The beneficial results of early and efficient splinting
in the case of compound fractures have been amply
demonstrated by the history of compound fractures
of the femur. (See page 59.) With the introduction
of the Thomas’ splint into regimental aid posts
and advanced dressing stations came an enormous
reduction of the amount of shock associated with
fractured thighs* and a corresponding fall in their

86 EARLY TREATMENT OF WAR WOUNDS

mortality. The same is true to a slightly lesser
extent of fracture of other bones. The better and the
earlier splinting is applied to a broken limb, the less
the patient suffers from the jolts and jars of his journey,
the smaller is the amount of damage done to the
tissues by the jagged ends of the bone, and, possibly,
the less are toxins massaged into the general circula-
tion. The wide-spread recognition of^these facts has
led to a striking improvement in the splinting carried
out by regimental and ambulance officers, and an
exceedingly satisfactory reduction in the degree of
shock commonly associated with fractured limbs.

There is, however, a limitation to the capacity of
splinting to neutralize the harmful effect of a long and
rough journey on a wounded man suffering from a
compound fracture. When the limb has been so
badly damaged that its subsequent amputation is a
matter of certainty, the earlier it is removed the better
it is for the patient. The splinting of these badly
smashed limbs is a difficult and painful process, and,
as they are frequently associated with haemorrhage,
conservative treatment becomes still more difficult.
Early amputation in the advanced dressing station is
called for far more frequently than it is performed.
Not only is it the safest treatment from the point of
view of shock, but it is often the easiest treatment
from the point of view of the medical officer.

The earlier that amputation is performed the less
is a general anaesthetic likely to be required. The
local shock to the tissues and the long latent period
of the patient’s nervous system generally allow of
the operation being more than half completed before

TREATMENT OF WOUND SHOCK

87

the patient realizes that anything is being done. The
site chosen for amputation is that at which the
minimum of cutting is required.

The effect on shock of the removal of a painful
and shattered limb is striking in the extreme. The
patient lapses into a condition of natural sleep, and
a few hours later may be evacuated with safety. If
a general anaesthetic has been given, the dangers of
subsequent acidosis are greatly increased by transport
so that the patient must be retained for a longer
period — 12-24 hours.

Effect of Pain and Anxiety on Shock, — Although
secondary shock may develop in the absence of pain,
it is found that severe and prolonged pain is a potent
factor in producing shock. Crile, in particular, has
laid stress on the importance of pain in this connec-
tion, Mental anxiety and worry produce a similar
exhaustion of the central nervous system, and rein-
force the baneful action of pain. The restless and
fretful patient rarely does well. All efforts to make
him comfortable fail, and even morphia may be with-
out effect. Prolonged consciousness, unbroken by
sleep, is in itself capable of producing symptoms of
secondary shock. Natural sleep is, in many ways,
worth more to the severely wounded man, who is
exhausted by all the excitements and exertions
of battle, than any other remedy that is known
to us.

The journey from the trenches to the casualty
clearing station is in any case an exhausting experi-
ence, and every effort must be made to spare the
wounded man all unnecessary exertion or worry.

88 EARLY TREATMENT OF WAR WOUNDS

Once his wounds have been satisfactorily attended to
— and this should be done as far forward as possible —
he should be left undisturbed. Redressing and un-
necessary stoppages should be avoided* Gentleness
in handling is essential at all stages. Nor can his
mental condition be neglected. Much can be done
by quiet assurance and encouragement to put his
mind at rest. The badly wounded man has, as a
rule, lost the control that carried him through the
trials and dangers that preceded his wounding, and
due allowance must be made for his abnormal mental
state.

Morphia has long been a bone of contention in this
connection. Its use is full of possibilities for good
and for evil, and considerable discernment is required
in deciding when to give and when to repeat an injec-
tion. Where the dangers of acidosis are not imminent
its use is likely to be wholly beneficial. When respira-
tion is slow and the skin is dusky in colour, morphia
may be productive of harm. The pros and cons of
each case must be carefully weighed, especially when
the question at stake is whether an injection should be
repeated or not. The opposing dangers of pain and
exhaustion, and of cyanosis and acidosis, must be
balanced in arriving at a decision, ( See also page 80.)

The Replenishing of Exhausted Reserves— As the
result of shock and of haemorrhage, the body suffers
two great losses, the loss of its fluid reserves and the
loss of its alkalis. As a corollary to the first of these
two losses we find a concentration of blood and to the
second a diminished alkalinity of the blood. In the
treatment of shock haemorrhage these two losses

TREATMENT OF WOUND SHOCK

80

must always be borne in mind, and steps taken to
replace the deficiency as early as possible.

The Administration of Fluids,— Two methods of
administering fluids to the depleted body are avail-
able :

(1) By means of the alimentary canal

(2) By intravenous or subcutaneous injection.

When circumstances permit, the first-named channel

of administration is of the greatest value. Very large
quantities of fluid must be given, a special orderly
being detailed to the duty of encouraging the wounded
man to drink repeated feederfuls of water. By means
of forced fluids alone Captain Robertson has succeeded
in raising a diminished blood volume to the normal
within a very short period.

Unfortunately, in many cases of shock, persistent
vomiting prevents the administration of anything
except a small amount of fluid by the mouth. In
such cases rectal salines are of value, although even
here difficulty may be experienced from the fact that
the sphincter acts but weakly, and the injected fluid
tends to return. To avoid this it is often advisable,
when possible, to administer fluids per rectum by
means of Murphy's drip.

Where the need of giving fluids is urgent, or where
administration by the alimentary canal is impossible,
recourse must be had to intravenous injections. Sub-
cutaneous infusion has its value in less serious cases,
but is less certain in its results. The various forms
of infusions available for intravenous injection will
be considered separately.

Intravenous Injections of Saline,— Numerous solutions,

90 EARLY TREATMENT OF WAR WOUNDS

of varying formulae, have been employed for intraven-
ous use, but one and all have proved disappointing
in their clinical results. During the last two years
much valuable work has been done by various
laboratory investigators on the subject of intraven-
ous injections, and a fuller knowledge of their action
has thereby been obtained. As a result of this work
it has been shown that intravenous salines are very
transitory in their action, and arc rapidly lost to the
circulation. No permanent dilution of the blood,
and no sustained raising of the blood pressure can be
obtained from the use of intravenous salines in cases
of severe shock-haemorrhage, A viscous fluid, which
will not readily be shed out of the vessels, is
required.

The Infusion of Colloids such as Gum Acacia,—

In the course of his investigation into the effect of
various intravenous infusions on the blood-pressure,
Professor Bayliss tested the action of such colloids
as gelatine, soluble starch, dextrin, and gum acacia.
A solution of between 6 and 7 per cent, of gum-acacia
in 0-9 per cent saline was found to have the same
viscosity as whole blood, and the same osmotic pres-
sure as the colloids of the plasma. It was therefore,
in theory, a suitable infusion for use in cases of shock-
haemorrhage. In the laboratory the value of such
an infusion has apparently been fully established.
Clinically it has not achieved the complete success that
it was hoped might result from its use. No laboratory
experiment can reproduce accurately the conditions
that arc met with in the field, and although gum may
establish its right to a place in the treatment of shock.

TREATMENT OF WOUND SHOCK

91

there is a very definite limitation to its powers in
raising and maintaining a fallen blood pressure.

As the length of time elapsing between the haemor-
rhage and the injection of gum, Le. the period during
which the blood pressure is seriously lowered, seems
to exercise an influence on the results obtained, and
as the use of gum had met with only partial success
at the casualty clearing stations in France, it was
decided to push the administration of gum forward
into the field ambulances. The injection would
thus be given in much more favourable circumstances,
a much shorter interval having elapsed since the
original haemorrhage. The treatment is still on its
trial. However, sufficient experience has been gained
to justify the following conclusions :

(1) That the infusion is more efficacious than normal
saline, when given within a few hours of wounding.

(2) That its administration is unattended by any
ill effect except an occasional rigor, or a tendency
to vomit,

(8) That in wounds of moderate severity accom-
panied by moderately severe haemorrhage, the ad-
ministration of gum-saline improves a man's general
condition, and allows of his being transported to a
casualty clearing station, w r hcrc blood transfusion can,
if necessary, be performed. (TO per cent, of success-
ful cases subsequently required the performance of
blood transfusion. )

(4) That in cases of severe shock - haemorrhage, or
where the interval since wounding is considerable
(10-12 hours), gum has little effect, and resort must
be had to transfusion of blood.

92 EARLY TREATMENT OF WAR WOUNDS

The Diminution of the Alkaline Reserves in Shock.

—The second loss that occurs in shock is that of
alkaline reserves (Cannon), A similar diminution
of alkali in the blood has been shown to occur in
haemorrhage (Milroy), in gas gangrene* after serious
temporary stoppage of circulation in one or more
limbs* and after exposure to severe cold (Almroth
Wright). Although the resulting acidosis is without
doubt a secondary, rather than a primary, phenome-
non in shock, nevertheless it is advisable to combat it
by the early administration of sodium bicarbonate.
The association of shock-haemorrhage and gas gan-
grene is a very common one, and the presence of
acidosis must always be regarded as a disquieting
possibility.

Cases of severe wounds accompanied by shock and
likely to develop gas infection should be treated as
early as possible with alkalis by the mouth. Where
acidosis has undoubtedly developed, an intravenous
infusion of sodium bicarbonate is indicated. In
less urgent cases the alkali may be administered per
rectum , Cases of extensive damage to muscle tissue,
as in wounds of the thigh and buttock, particularly
call for treatment by alkalis. It must be noted that
such wounds are especially prone to the development
of gas gangrene.

It must also be remembered that even in the normal
person there is a change in the blood in the direction
of acidosis during the course of a surgical operation
(Cannon). In the shocked individual this change is
proportionally greater, and is attended with consider-
able danger.

TREATMENT OF WOUND SHOCK 93

It should be combated by means of alkalis, and by
the employment of nitrous oxide and oxygen as an
anaesthetic.

Sir Almroth Wright has, moreover, called attention
to a possible danger from acidosis when a hot-air bath
is used to raise the temperature of a man in a severe
state of shock* Asa result of the warming of the body
and of the improvement in the circulation, acid
products are likely to be washed out of the muscles
into the blood-stream, producing a sudden and severe
acidaemia. To avoid such an event, resuscitation
should be preceded by a free use of alkalis.

Blood Transfusion, — Nothing has been more striking
than the rapid spread of the use of blood transfusion
as a therapeutic measure for the combatting of shock-
haemorrhage. During the first two years of the war
transfusion was performed only by a few specially
experienced surgeons, and was regarded more as an
interesting curiosity than as a practical measure in
the treatment of shock. It is only during the last
two years that its scope has been realized, and that it
lias been adopted as a recognized part of the treatment
of the severely wounded man.

It is not proposed to enter into a description of the
various methods of performing transfusion in use at
the present moment, or to discuss their comparative
advantages. These details may be obtained from
various text-books on the subject, or, preferably, from
the memorandum recently published by the Medical
Research Committee. It is proposed rather to deal
with the scope of blood transfusion in war surgery,
and with the indications for its use. In the Army in

94 EARLY TREATMENT OF WAR WOUNDS

which the writers have worked, the method that
has been almost universally adopted is the citrated
method described by Captain 0. H. Robertson in the
above-mentioned memorandum *of the Medical Re-
search Committee. Its chief advantages arc its
simplicity, and the fact that no special apparatus is
required beyond glass tubing, rubber corks, and
suitable needles. Not only has this method rendered
blood transfusion a feasible proceeding at all casualty
clearing stations, but has allowed of its being pushed
forward, under certain conditions, into the dressing
stations of the field ambulances. Its extensive use
throughout this Army has undoubtedly resulted in
the saving of many valuable lives.

No transfusions ought to be performed without a pre-
liminary blood test, and a determination of the groups
to which the donor and recipient belong. The simple
technique of Moss is employed, and, as a rule, only
the blood of members of number 4 group (the universal
donor) is used. A list of available donors is kept at
each casualty clearing station, so that blood may be
obtained at short notice whenever desired. Donors
are selected from amongst the lightly wounded, from
the personnel, and from those convalescing from
trifling ailments* While freedom from syphilis,
malaria, and other blood-borne diseases is theoretically
essential, specific tests for these can be carried out
as yet only in rare instances, and reliance must be
placed on the statements of the donors* After
bleeding, the donor may be kept in bed for 24-48
hours, and is then allowed a few days’ rest* No
ill effects result from the bleeding, and the blood

TREATMENT OF WOUND SHOCK 95

loss is made good probably within three or four
days.

Transfusions at Casualty Clearing Stations, — Trans-
fusions are most successful in those eases of shock
in which haemorrhage has played a considerable part,
so that the patient is suffering from acute anaemia.
The cases that answer par excellence are severe
limb injuries, associated with damage to important
blood-vessels. Statistics are of little value in deter-
mining the value of transfusion, but in a series of
eases recently treated at a casualty clearing station
by Captain 0, H. Robertson the mortality after
transfusion was 28 per cent, in the case of large single
wounds (chiefly fractured femurs), whereas with
abdominal wounds it was as high as 71 per cent. In
both classes of wounds only the worst cases, such as
would almost inevitably have died without it, were
selected for transfusion.

Although satisfactory results are less certain in
those eases in which the shock element predominates
over the haemorrhagic, nevertheless transfusion is
of use in the treatment of shock, the mortality rate
for this class of ease in the above quoted series being
in the neighbourhood of 50 per cent.

The quantity of blood transfused at a single sitting
has varied from 250 c.c. up to 1,000 e.c. When severe
haemorrhage has taken place the quantity of blood
should be large. No hesitation should be displayed in
giving a second dose, when this appears desirable. In
shock, on the other hand, it is preferable to give smaller
quantities, and to repeat if necessary. As a remedy for
sepsis, transfusion would appear to be of little value*

96 EARLY TREATMENT OF WAR WOUNDS

Indications for Transfusion.— Owing to the fact that
blood is an expensive remedy, both as regards time
and material, it is particularly necessary to arrive at
a clear understanding as to the indications for its

use.

During a rush of work at a casualty clearing station,
a decision as to the advisability of carrying out trans-
fusion must rest on clinical grounds rather than on
more exact methods. Govaerts has stated that help
in estimating the severity of the haemorrhage that has
occurred can be obtained from a red cell count* He
lays down the rule that if, within six hours of wounding,
the red cells are found to be below four million, trans-
fusion should be carried out. In view of more recent
work on blood volume in haemorrhage and shock it is
doubtful if the blood count is of so much value as an
indication for transfusion as Govaerts would have us
believe.

A more convenient aid to arriving at a decision on
the question of transfusion is the sphygmomanometer.
Successive readings are taken of the blood pressure,
and if, as the result of ordinary treatment, such as
warmth and rest, reinforced by rectal salines or the
simpler intravenous infusions, the pressure shows no
tendency to rise, transfusion is generally required.
A blood pressure of 85 mm, of mercury is regarded
generally as the minimum level at which a patient
can be operated upon with safety. If other methods
of resuscitation fail to bring the pressure to this level
a pre-operative transfusion must be performed*

Pulse rate is of value in cases of haemorrhage, but
gives little information as to the actual condition of

TREATMENT OF WOUND SHOCK 97

thc P atlcnt wIi en shock is present. A steadily rising
pulse rate is, of course, of ill omen. So also are a
quickening of respiration and an increase of cyanosis.
Care must be exercised not to mistake the “ euphaemia”
that sometimes occurs with the onset of gas gangrene
for a true improvement. The rise in the pulse" rate
that accompanies the increase in the blood pressure
in cases of gas infection should put the observer on his
guard. The occurrence of vomiting, and thc charac-
teristic change in the patient’s facies, associated with
the onset of gangrene, should help to prevent mistakes
in many of the cases.

It must be remembered that the majority of fatali-
ties after transfusion are due to sepsis, death usually
occurring some two or three days subsequently,
hor this reason, too long an interval must not be al-
lowed to elapse before operation. If, as the result of
other methods of resuscitation, the patient is not fit
lor operation (as judged by the blood pressure and
other criteria) within, at most, six hours of entry into
the casualty clearing station, he should be given
the benefit of transfusion.

When the operation is of necessity a long one or
is likely to be followed by dangerous collapse, every-
thing must be ready for the performance of post-
operative transfusion should this become necessary.
In cases in which bleeding is still going on ( e.g , in
abdominal cases) transfusion should be postponed
until the injured vessels have been found and the
haemorrhage controlled, but should then be given at
once if possible. Should blood not be immediately
available an intravenous injection of alkali or of gum

98 EARLY TREATMENT OF WAR WOUNDS

may be given as a temporary expedient, and the
patient transfused on his return to the ward*

Transitu sio 11 with Preserved Blood Cells, The fact
that blood corpuscles may be preserved by means
of dextrose and have been stored on ice for as long
as four weeks without losing their viability was first
proved by Rous and Turner, working at the Rocke-
feller Institute. The discovery has a practical bear-
ing, in that it permits of blood being drawn off during
periods of quiet and stored ready for future use.
Preserved blood was first used on a large scale by
Captain O. H. Robertson when working at an advanced
casualty clearing station during a battle in autumn,
1917 . The results achieved were apparently as good
as those obtained from the use of fresh blood, and in no
ease were ill effects noted.

Since that time preserved blood has been used on a
great many occasions, and is now recognized as a very
valuable asset in the treatment of shock-haemorrhage.
The chief advantage of this method of transfusion
lies in the convenience of having a large quantity of
blood on hand for a rush, A second advantage is the
fact that, once the blood has been drawn off, it may be
transported to wherever it may be required and given
with almost the same ease as an intravenous injection
of saline. The bearing of this on advanced resuscita-
tion work will be found in the following paragraph.
Details of the technique employed in transfusion with
preserved blood corpuscles can be obtained from
the memorandum published by the Medical Research
Committee on that subject.

Transfusion in the Forward Area.— As the hopes that

99

treatment of wound shock

infusion with Bayliss’s solution of gum acacia might
give results comparable with those obtained by the
use of blood were not entirely realized, the question
of the possibility of performing transfusion in front
of the casualty clearing station presented itself.
Considerable difficulties attend the performance of
transfusion in advanced positions, but during quiet
times these difficulties are by no means insuperable.
Already quite a number of early transfusions have
been performed, both with preserved and with
fresh blood. When supplies of the former are avail-
able the difficulties of transfusion are considerably
diminished, and arrangements have been made in one
of the armies in France for a supply of preserved blood
to be sent up when required from the casualty
clearing station to the main dressing station in front
of it. Such an arrangement can always be made on
the eve of a raid or other minor engagement. If any
of the blood is not used and is kept cool, in a special
small ice-box, it is returned at once to the casualtv
clearing station and made use of there.

A certain number of transfusions have been per-
formed even as far forward as the regimental aid post
by the enterprise of such men as Captain Guiou of the
C. A.M. C. Patients have thereby been saved who would
not otherwise have reached the main dressing station,
but, on the other hand, a certain percentage of those
who have been revived by these means have later
succumbed to the shock of the long journey back to
the casualty clearing station. In any ease, the
knowledge that preparations have been made in the
battalion aid post for the saving of even the most

100 EARLY TREATMENT OF WAR WOUNDS

desperately wounded is not without effect on the
morale of those “going over the top.”

Although early transfusion is a valuable asset
when it is feasible, it must always merely supplement,
and never replace, sound general treatment. To
transfuse a man in a forward dressing station, and
then send him down with a shattered limb on which a
tourniquet is applied* is unsound treatment, since it
leaves unremedied the chief cause of his shock. The
limb must be amputated and the tourniquet removed.

In times of battle, when great numbers of wounded
are being dealt with, early transfusion becomes an
impossibility, except, during lulls, at a large, well-
equipped dressing station which has been previously
stocked with a supply of preserved blood.

After transfusion it is desirable to keep the wounded
man for at least an hour before sending him on his
journey. By this time the beneficial results of the
transfusion will have become manifest, and any
tendency on the part of the wounds to bleed will have
been detected.

Operations and Anaesthetics in Shock*— The question
of when to operate in the case of a severely shocked
man is one of great difficulty. A balance must be
struck between the danger of operating while the
patient is still in a state of shock and the danger of
waiting so long that sepsis has got well ahead. A
very large number of cases are revived from shock, only
to die a few days later from the toxaemia of sepsis,
so that it is of the utmost importance that operative
treatment should not be postponed an hour longer
than is necessary. In deciding when a patient has

TREATMENT OF WOUND SHOCK 101

revived sufficiently for operation, the sphygmomano-
meter is a valuable help* A blood pressure of 85 or
over will generally allow a previously shocked patient
to face an anaesthetic and an operation, provided the
anaesthetic is suitable and the operation a rapid one.
In performing the operation two aims should be kept
in view: the first, rapidity, and the second, complete-
ness in dealing with sepsis. When the ultimate
saving of a limb is of doubtful achievement it should
be sacrifled without hesitation. The patient must be
left with the minimum possibility of septic absorption,
for the danger that lies in front of him is death from
the toxaemia of sepsis.

Of the great value of nitrous oxide and oxygen as
an anaesthetic in cases of shock there can be no doubt.
Its superiority over all other general anaesthetics has
been amply proved by various authorities, and its use
in such eases has now become general.

On the subject of spinal anaesthesia much less
uniformity of opinion exists. Although Captain G.
Marshall, R.A.M.C., has found that the use of spinal
anaesthesia in eases that have recently suffered a
severe haemorrhage is attended with grave danger,
others have employed intraspinal injections with
considerable success. Dcsplas (France) in particular
urges its more extensive use in cases of severe in-
juries of the lower extremities, accompanied by
shock. All authorities agree on the importance of
the technique to be employed. The anaesthetic
should be combined with inhalations of oxygen,
and care taken to eliminate, as much as possible,
disturbance of a psychical nature. A preliminary

102 EARLY TREATMENT OF WAR WOUNDS

injection of morphine, and, when the necessary
turning of the patient on his side is likely to cause
great pain, an initial use of gas and oxygen, will
help to eliminate pain and mental distress* Trans-
fusion should be done before, during, or immediately
after the operation according to indications in each
case. In other injuries nerve blocking, and, in the
upper extremity, Bier’s intravenous method of
anaesthesia have been employed with gratifying
results.

Conclusions, — From the foregoing it will be seen
that no sovereign remedy exists for the treatment of
shock. Since secondary shock is the outcome of the
action of such factors as haemorrhage, pain, cold, and
exhaustion on a severely wounded man, our efforts
must constantly be directed to the task of reducing
these harmful influences to a minimum, and thereby
preventing its onset or further development. This
can only be done by constant attention to a hundred
little details, which, considered alone, may appear
trifling, but considered in their entirety are of the
utmost importance.

Establishment of Special Shock Centres, — It will
be appreciated that much knowledge and many
technical procedures, in which the general body of
medical officers had previously no special training,
had to be disseminated and demonstrated. This was
done, in the Army to which reference has repeatedly
been made, by means of conferences, for the discussion
of shock problems and for the report of progress in
various directions, and by the establishment of a
special army shock centre* This centre was initiated

TREATMENT OF WOUND SHOCK 103

in the autumn of 10 17, and has proved to be of inesti-
mable value. Its functions were :

(a) To co-ordinate as far as possible the work on

shock in the casualty clearing stations and
units in the forward areas, and to foster
co-operation *

(b) To collect and epitomize reports from

medical units of the Army ;

(c) To test the practicability and utility of

remedial measures before they were sanc-
tioned officially, and, in conjunction with
administrators, to arrange means whereby
approved remedies could be used to the
greatest advantage ;

(d) To provide facilities in the way of providing

materials, special fluids, testing sera, etc,,
to units which had difficulty in obtaining
these otherwise ;

(e) To keep in touch with centres where research

in shock work was being carried on, especi-
ally with the Medical Research Committee,
and to keep abreast of current literature
on shock ; to disseminate information thus
gained to the units or workers whom it
especially concerned ;

(/) To act as a technical training centre for
divisional officers, so that they might be
fully conversant with suitable methods of
examination and treatment of shock ;

(g) To carry out such scientific investigations as
required special laboratory equipment ;
and

104 EARLY TREATMENT OF WAR WOUNDS

(h) To issue reports from time to time of the
shock work done in the Army,

REFERENCES

(1) Journal of American Medical Association, vol, lxx. No, 9, page

617, Major W. B. Cannon, M.O.R.C,, U.S.A.

(2) The Lancet , Juno 1st, 1918. Colonel Sir AJmroth Wright, C.B ff

ete,

(3J Journal of Physiology, 1917. Professor Milroy.

CHAPTER IV

# t

CONSIDERATIONS REGARDING TIIE USE OR DIFFERENT
KINDS OF ANTISEPTICS AND DRESSINGS

At the beginning of the war most surgeons were
strongly imbued with the faith that antiseptics pro-
vided all that was essential for successful treatment
of the appalling sepsis which faced them. Their
ensuing struggle against sepsis may well be likened
to that in the present war against the “ bodies.”
In both cases, old weapons and methods of attack,
although not entirely discarded, have been largely
replaced by new ones, while others, older still, have
been revived.

Sir Almroth Wright’s able and stimulating work
had much influence in gradually weaning the pro-
fession from the established faith, and in fostering
reliance, so to speak, on the powerful natural reserves
which can be called upon to cope with invading
organisms. It had, however, to be demonstrated
that no real safety can be ensured until the strong-
holds of these organisms have first been demolished.
These strongholds are formed in the muscles and other
structures torn by missiles. Antiseptics affect bac-
teria imbedded in these no more than shrapnel or
rifle fire dislodges the Hun lurking in fortified dug-

105

106 EARLY TREATMENT OF WAR WOUNDS

outs, although both may be quite effective “ in the
open.” To carry the simile further, excision of
lacerated tissues corresponds to ruthless but well-
planned destruction caused by a bombardment.
Intensive “ training ” of reserves is represented by
the reactionary development of anti-bodies, which is
aided by the injection of anti-tetanic and other sera.
Demoralization of these reserves, comparable in the
war of nations to that brought about by long-range
shelling, bombs, pacifist propaganda, or other agencies,
is counteracted by measures which cope, for example,
with the fall of blood pressure or with acidosis pro-
duced by insidious pathogenic agencies in so many
different ; ways. The strength of allies has been
demonstrated in the marvellous effects of transfusion
of blood.

All these are elements really of counter-attack
alone. While the best defence is in attack, yet pre-
cautions must be taken to prevent a successful break
through, whether by raiders or by overwhelming
masses. The front positions, in which the defensive
attacking forces must congregate and from which
they strike, must be made as invulnerable as possible.
Their natural advantages must be conserved and
strengthened.

Individual cells form the front line of tissues which
face the battle-field. A healthy cell will resist the
attack of organisms and their toxins until its envelop-
ing membrane is broken down or penetrated in a
way comparable to the destruction of resistance
offered by wiring or gas-resisting appliances. There
is reason to believe that this inherent power is con-

ANTISEPTICS AND DRESSINGS

107

served by the use of a defensive insulating medium
such as liquid paraffin, which has become so popular
recently as a compounding vehicle in applications to
wounded surfaces, (1 > The question of the regulation of
“ electrical s> energy in the treatment of wounds has
come into prominence in this connection. Formerly
only chemical or mechanical factors have been con-
sidered. The subject is in such a state of flux, how-
ever, that one prefers to leave its elaboration to those
more qualified to deal with it. It is to be hoped that
the question will be thrashed out fairly by competent
authorities.

It cannot be emphasized too urgently that the use
of antiseptics will not make up for inadequate opera-
tive treatment. It can be safely said also that u the
stronger the antiseptic, the worse the result . 35 The
reasons for this need not be discussed, but the fact
should be remembered when a particularly soiled
wound tempts the use of strong remedies, or when one
vaunted antiseptic is tested against another. On the
other hand, provided that operation is adequate, one
kind of rational after-treatment does not seem to
influence the patient’s chance of life or limb much
more than another. The results claimed by the sup-
porters of apparently widely varying methods do
not differ very greatly. It is doubtful indeed whether,
after proper operative treatment, a w r ound treated
by antiseptic methods behaves any better than one
treated by aseptic methods. Even in the same
patient one wound differs in behaviour from another
treated in identical fashion. This difference seems
to depend mainly on the adequacy of the blood supply

108 EARLY TREATMENT OF WAR WOUNDS

and the character of the tissues exposed at operation.
For example, fibrous and especially aponeurotic or
tendinous structures tend to slough more readily than
purely muscular tissues. Wounds of the scalp and
face heal very kindly and rapidly when properly
treated, and at the same time will overcome success-
fully a relatively greater amount of infection than
will wounds of parts less well supplied with blood.

The kind of dressing which will best assist Nature’s
endeavours in the processes of healing is that which is
most to be recommended. If the source of infection
and the already deeply infected tissues are removed,
it is doubtful, as has already been stated in different
words, whether Nature requires any extraneous help
in the form of antiseptics. Remedies which will aid
the local and general resistance by restoring or
enhancing the natural power of cells and body fluids,
have been aimed at by many, and arc being steadily
elaborated ; but it is difficult, and, in the present state
of our knowledge and training inadvisable, to discard
antiseptics altogether. They “ catch the enemy in
the open.” Therefore, although the dressing applied
in or on a wound should cause the minimum amount of
delay in local reparative processes, yet, because our
efforts in procuring asepsis arc liable to be inadequate,
that dressing should contain a sufficient proportion of
a non-poisonous antiseptic, or a harmless amount of a
poisonous one, to prevent organisms from developing
in the fluids which are exuded from the wound
surfaces. These antiseptics will be of use only if the
wound has been so prepared that direct action on
any remaining sepsis is possible.

ANTISEPTICS AND DRESSINGS

109

A dressing that does not require frequent attention
should be used whenever possible. Routine changing
of dressings should be avoided. No gauze pack, for
example, should be removed without a definite object,
such as closure of the wound or investigation of the
cause of sudden pain. Dressings should be capable
of being easily and painlessly removed.

The writer believes that all these requirements have,
so far, been met best by the judicious use of solutions,
emulsions, or pastes of various antiseptics in liquid
paraffin. When used in a wound, paraffin holds
antiseptics in suspension or solution for a longer
time than does water or spirit. The antiseptics which
have been most frequently employed up to the
present, along with paraffin, are flavine ( 1-1,000),
brilliant green (1-500), (2)(3) iodoform (1 per cent) boric
acid, and chloramine T, The boric acid is usually
mixed with other antiseptics in sufficient quantity
to form a paste of the consistency of soft butter.
Wounds, after operation, are smeared with one or
other of these applications, and are either sutured or
packed lightly with gauze impregnated with plain
paraffin, or, better, iodoform paraffin (1 per cent.).

Some substances, e.g . iodoform, when used in a
dressing, exert an antiseptic effect only when they
are broken up in contact with body fluids. As this
dissolution occurs slowly, their action spreads over
a long period when compared with that of such an
antiseptic as cusol. The term £t depot antiseptic ”
has been applied to them.

The advantage of a constant supply of antiseptic
from a depot is appreciated by users of Carrel’s

no EARLY TREATMENT OF WAR WOUNDS

method ; but, the more simple and automaticthe depot
arrangement is, the more suitable it is for work at
advanced units. A depot on the spot, that is, in the
wound, would seem to be the most advantageous.

R.I.P. Paste (bismuth subnitrate 1 part, iodo-
form 2 parts, paraffin liquidum q.s., recommended
by Professor Rutherford Morison) must be used
sparingly in recent wounds, otherwise severe symp-
toms of poisoning may ensue. A small quantity of
the paste should be carefully rubbed into the surfaces
and pockets of the wound, especially of “ sus-
picious ’’ parts, and thereafter the visible excess
should be wiped away with a pledget of gauze.

The “ salt pack, - ’ founded 911 Sir Almroth Wright’s
work onthe “physiological” effects of various strengths
of salt solution, and introduced by the writer in 1915,
gives excellent results, but lias largely been given up
in favour of the “ paraffin pack.” Owing to its
lymphagogic effect, the salt pack is apt to cause an
undue strain on patients already in want of bodv
fluids. Where, however, equilibrium in this respect
has been established, and where there is much in-
flammatory swelling around a wound, it may still be
used with advantage. The complete absence of
inflammation in or around wounds treated bv this
method, and the paucity of bacteria in the depth of the
wound after twenty-four to forty-eight hours, indicate
the practicability of performing delayed primary
suture (see page 165). This has been carried out
with success in several cases. A disadvantage of this
pack is that, during the first five or six days, it is
so adherent that bleeding is caused by its removal.

ANTISEPTICS AND DRESSINGS

111

Although the salt pack suffered in repute owing to
want of attention to important details in its
application, it helped to pave the way for the
popular modem method of treating open wounds
with gauze fillings, and had considerable influence
also in altering the practice of frequent redressing
to which patients were subjected in the early
days of the war. If the wound is not suitable for
delayed primary suture, the salt pack makes an
excellent dressing, and may be left undisturbed until
it becomes quite loose. At intervals of a few days
the superficial dressings should be changed and the
surrounding skin disinfected.

The following extract is taken from a paper by
J. E. H. Roberts and R. S, S, Statham. Their
remarks are of special interest in view of the date
of their publication C4) (August 26th, 1916), and of the
methods of treatment which they had been using
at the Base for more than a year previously.

“ The method of dressing wounds with a firm pack
of gauze and sodium chloride tablets, devised by
Colonel H, M. W. Gray, C.B., combined with a pre-
liminary free excision of the wound and lacerated
and infected tissues, has in our hands given results
which have effected revolutionary changes in our
methods of treatment. During the last twelve months
it has gradually supplanted other methods of treat-
ment, until now w f c employ it in the majority of
cases. At first we regarded it with suspicion and
used it but half-heartedly ; finding, however, that
wounds dressed in this w ay became clean at least as

112 EARLY TREATMENT OF WAR WOUNDS

speedily as those treated by other methods, and that
the general condition of the patients improved owing
to undisturbed sleep, increase of appetite, and absence
of mental apprehension of frequent painful dressings,
we ended by becoming complete converts to the
method,

** The operative details in connection with a wound
naturally vary with the site, nature, and degree of
infection of the wound.

“ For example, wounds of the buttock by shrapnel
ball or shell arc invariably laid open in their whole
extent. If there are separate entry and exit wounds
they are joined by an incision dividing the glutei
down to the track between them. Foreign bodies
are removed and the necrotic tissue lining the track
excised. Bleeding points arc tied with catgut, and
after examination for bony or visceral lesions a salt
pack is applied. Such a wound is often ready for
suturing within ten days to a fortnight,

“ Wounds of Limbs *— The superficial wound, if small,
is excised so that it will admit a finger. The full
extent of the wound is then determined as far as
possible by digital examination, and, unless essential
structures are involved, the whole area is laid open,
all pockets being exposed to the end. Foreign bodies,
including pieces of cloth and blood-clot, are carefully
searched for and removed, and all necrotic tissue cut
away with the scissors until a freely bleeding surface
remains. If the deep fascia or superficial muscles
tend to come together and close the mouth of the
wound, sufficient tissue is excised to ensure that, when
the salt pack is in place, the mouth of the wound will

ANTISEPTICS AND DRESSINGS Il3

be widely open* A conical wound not. requiring the
use of drainage tubes is thus produced*

“ Where there exist entry and exit wounds and
their junction would involve the sacrifice of essential
structures, such as a large motor nerve* two conical
excisions, with their apices meeting in the centre of the
track, may be made and a pack applied at each end.

“ In all cases side-tracks and pockets are opened
up so that they may be packed to the bottom. Where
a fracture exists, fragments, unless small and com-
pletely detached, arc not removed. These proceed-
ings are not really so heroic as at first sight may
appear, for, first, most of the muscle excised is in-
fected, and, secondly, it has been shown that muscular
tissue, even though not infected, has lost its striation
and contains haemorrhagic areas for a considerable
distance around a gunshot wound. Such muscle will
not regain its function, and will ultimately be replaced
by fibrous tissue. Fascia and tendinous structures
are badly supplied with blood and invariably slough
when exposed in infected wounds. They should be
cut away at the primary operation. On the other
hand, the sheaths enclosing intact muscles should not
be unnecessarily opened. When infection is confined
to a single muscle it is sometimes advisable to remove
the whole belly in its sheath ; for instance, the rectus
femoris or one of the hamstring group. Thrombosed
veins should be dissected out to their full extent and
excised*

“ With the exception of iodine for the skin we do
not apply any antiseptic to the wound,

“ The wound having been thus prepared, the salt
8

y

114 EARLY TREATMENT OF WAR WOUNDS

pack is applied in the following manner* A piece of
plain gauze, four to six layers thick, is lightly wrung
out of 5 per cent* salt solution and carefully laid in
the wound so that it is in contact with the whole of
the surface* Care should be taken that this sheet
of gauze is sufficiently large to cover the whole surface
of the wound* If several smaller overlapping pieces
are used, small spaces in which pus collects form at
the lines of junctions and there is also great danger
of the pieces being displaced when the rest of the
packing is inserted, thus leaving bare surfaces* When
the wound is a deep one the gauze lining is carefully
carried down by the fingers within it to the deepest
recesses of the wound* No spaces should be left, as
they rapidly fill up with pus* A few forty grain
tablets of salt * are now placed in the deepest part
of the wound, or, if the wound is flat, placed on the
surface of the gauze, about an inch apart. The interior
of the gauze-lined wound is now firmly packed, some-
what in the manner of the old-fashioned petticoat cd
tube, with a roll or long strip of gauze moistened in
the same way* This strip is carried alternately from
one end of the wound to the other and numerous
tablets of salt arc laid between the successive layers.
A handful of tablets should not be thrust in altogether,
as when they dissolve a cavity is formed* For a
wound 4 in* long by 3 in* deep ten to twenty tablets
would be used. When the pack becomes flush with
the skin surface a few more layers of gauze are applied
and over that a thick wool dressing, composed of at

* These tied up in convenient numbers in small gauze bags may
be sterilized along with other dressings in the autoclave,

ANTISEPTICS AND DRESSINGS

115

least three layers, completely encircling the limb. The
whole is then firmly bandaged, so that the surface of
the wound is kept in intimate contact with the pack,
and all spaces which tend to form are obliterated.
Really firm pressure should be used both in applying
the pack and in bandaging- The elasticity of the
thick wool dressing distributes the pressure and effec-
tually prevents anaemia of the wound surface and
congestion of the wound below,

“ Where a compound fracture is present it is not
usually possible to avoid leaving spaces between and
around the fragments of bone, and therefore in such
cases, after placing the lining sheet of gauze, a large
rubber tube is introduced down to the fracture, and
the remainder of the gauze and tablets packed around
it. This serves to prevent the tracking of pus along
the bone. A hole cut in the lining gauze allows any
discharge to gain free access to the tube.

“We have frequently packed on to exposed main
arteries, such as the femoral, brachial, and subclavian*
In no case has the vessel given way, but we have
been careful to interpose a rather greater thickness
of gauze tli an usual between the hard tablets and
the vessel. If a salt tablet comes into direct contact
with the tissues it causes a necrotic area a little
larger in diameter than itself, but quite superficial,
its depth being not more than a millimetre. This is
really of little importance, as it disappears by the
next dressing, but is better avoided. It appears to
be quite safe to pack on to exposed surfaces of bone.
During the first twelve to twenty-four hours a
copious exudation of serum occurs, soaking the gauze,

116 EARLY TREATMENT OF WAR WOUNDS

wool, and bandage. After this no further exudation
usually takes place, and, if the dressings arc inspected
during the next four or five days, they are generally
discovered to be quite dry. As soon as the outer
layers of the dressing become moist a packing of fresh
sterile wool is placed outside without removing the
bandage.

“It is important that the wound should be kept
at rest. In large wounds of limbs we employ a splint,
but in smaller wounds the nature of the dressing,
with its firm bandage and the fact that the serum-
soaked outer gauze dries into a hard mass of the
consistency of a starch bandage, renders a splint
unnecessary.

“ After dressing, morphine tartrate, grain is
usually given, as most patients complain of pain for
a few hours. In many cases, however, the pain is
quite slight, and no analgesic is necessary. In the few
cases in which pain has persisted, exposed sensory
nerve endings have been discovered, and these may
be cut short under novocain. Successive dressings
become less painful, and after the second an analgesic
is usually unnecessary, A rise of temperature and
increase of pulse-rate usually follows the manipula-
tions, but unless these persist after twelve to twenty-
four hours no apprehension need be felt,

“ In the behaviour of the temperature and pulse
the cases fall into three main classes. In the larger
number the temperature and pulse -rate fall to normal
on the second day and remain so, except for temporary
slight rises following the first dressings.

“In another class the pulse-rate comes down at

ANTISEPTICS AND DRESSINGS

117

once, but the temperature comes down by lysis, taking
four or five days to reach the normal. In a compara-
tively small number of cases, although the pulse-rate
remains below 90, the evening rise of temperature
may persist for one or two weeks, although the wounds
when dressed appear clean and free from retained pus.

“ The pulse-rate and general condition of the patient
is a much better index of the well-being of the wound
than the temperature.

After a few days the outer dressings may acquire
a very offensive odour. This is due to decomposition
in the dressings themselves, and if they are removed
the wound is found to be perfectly sweet. The outer
dressings are more offensive than the inner. At one
time we changed the outer dressings when they began
to smell, leaving the packing in the wound untouched.
The objection to this is that it is difficult to change
the outer dressings without disturbing the deep pack.
We then used various substances, such as sanitas
powder, potassium permanganate, and eupad powder,
thickly dusted on the dressing immediately beneath
the outermost layer of gauze. All these diminish the
odour. With Dakin's chloramine-T powder, which
we are now using, all odour is practically abolished.
Mixing chloramine-T tablets with the salt tablets in
the deeper dressing was found to be unsatisfactory,
as it did not prevent the smell.

u The Normal Favourable Course . — The course of
events in an ordinary, fairly severe, infected wound
of the soft part is as follows : After excision and
packing the dressing is untouched for five or six days :
the wound is then dressed, usually under an anassthe-

118 EARLY TREATMENT OF WAR WOUNDS

tic. In the majority of cases the pack is now loose,
and the dressing comes away as a whole. 1 he surface
of the wound is covered with a yellow frbri no-purulcnt
exudate, w r ith here and there a few small yellow
sloughs where damaged muscle or aponeurosis has
been incompletely removed. A small amount of
creamy yellow “ laudable ” pus is seen in the wound,
quite different in appearance from the original, brown-
ish, stinking, anaerobic pus. If the surface of the
wound is swabbed, some of the exudate is removed,
exposing a readily bleeding surface underneath. The
muscle is no longer cede mat ous and does not project
beyond the skin surface, which is quite healthy and
show's no sign of surrounding inflammation. The skin
is sw'abbed with iodine and a fresh salt pack is applied,
smaller in dimensions than the primary one. The
pressure of the wound surface against the gauze pack
is re-established when the firm bandage is applied.
This dressing is changed in another five or six days,
and the whole surface of the wound is now seen to
be covered with brilliant red, easily bleeding granu-
lation tissue, all sloughs having separated. If some
areas are not yet clean, another pack is inserted,
otherwise the w'ound may be brought together with
strapping or may be sutured. The majority of wounds
of soft parts are ready for closure within three weeks.
Some have been closed as early as the tenth day. The
time which is required before a w ound is in a fit state
to close varies in accordance with the nature of the
tissues exposed. Thus muscular tissue rapidly be-
comes clean. Tendinous and fascial sloughs take
longer to separate. Pieces of dead bone take so long

ANTISEPTICS AND DRESSINGS

119

that it is inadvisable to close a wound complicated
by a fracture,

“ Indications for changing the Pack ; — Indications
that the wound is not doing well and that the pack
must be changed are :

u L A continuously rising pulse-rate,

“ 2. Increasing oedema in the limb.

41 1 3. Sudden onset of severe pain. This generally
means spreading gas infection,

“ 4. A persistent rise of temperature for which no
other cause can be found.

u 5. A change for the worse in the patient's general
condition in cases in which a raised temperature has
persisted from the beginning,

“ 6. Oozing of pus from under the edge of the
dressing. This is generally due either to the dressing
having been left unchanged too long, or having been
too loosely applied,

44 7. The dressing must be reapplied when the pack
has become loose from diminution in the circumfer-
ence of the limb as oedema disappears.

u Some Other Details . — Where the innermost layer
of gauze is found to be firmly adherent to the wound
surface it is not removed, but a new pack is applied
within it. If it is removed bleeding is caused, the
protective barrier is broken down, and a rise of
temperature takes place.

“ When once the wound is granulating healthily it
is not advisable to continue the salt pack, as the
granulations become exuberant, pale, and oedematous.
If the wound cannot be closed, any of the simple
dressings should be applied.

120 EARLY TREATMENT OF WAR WOUNDS

“ Occasionally a wound becomes sluggish, even
during the separation of sloughs. A change from
the salt pack to a dressing of gauze soaked in pure
glycerine usually causes a rapid change for the better.
Where a wound is not doing well with a salt pack,
and a pure streptococcal infection is present, the use
of a 1 per cent, salt solution as a wet dressing, con-
tinuous irrigation, or bath will sometimes be found to
effect an improvement.

“ Conclusions . — The salt pack has given very good
results. ... It appears to be of great value in field
ambulances and clearing stations, as in time of stress
it may be impossible to renew dressings for two or
three days. Those cases we have received from clear-
ing stations in which the treatment has been thor-
oughly carried out have arrived in excellent condition,
and contrast very favourably with those treated by
other methods. Cases treated by eusol irrigation,
however clean they may be when leaving the clearing
station, often have their wounds in an unsatisfactory
state on arrival at the base twenty-four hours later,

“ Our advocacy of this method of treating wounds
is based entirely on our clinical experience, and we do
not in this place advance any theories to explain its
action. It is based originally on the well-known work
of Sir Almroth Wright.”

The rapid digestion and loosening of sloughs and
the characteristic odour which occur in most cases
have been stated by R, Donaldson and J. Leonard
Joyce to be due chiefly to what they have called the
“Reading bacillus.” <*> Wounds which are not in-

ANTISEPTICS AND DRESSINGS

121

fected with this bacillus do not clean so rapidly, and
indeed may seriously deteriorate, so that recourse
must be had to some other form of treatment. These
writers have found that the condition of the wound
as well as the general health of the patient improves
at once if a culture of this non-pathogenic bacillus is
smeared over the surface anti the pack renewed.
They suggest that the culture should be applied
deliberately at the end of the primary cleansing
operation, {This should only be done if the wound
cannot be closed at an early date,) Large wounds
are usually ready for closing after two applications
of the pack, on an average apparently of about ten
days. The amount and density of the fibrous tissue
composing the slough influence the length of time
required for separation. They have had equally good
results from using plain gauze or sphagnum moss
packs. (The author thinks that the addition of salt
to the first application, in the form of tablets dis-
tributed at intervals of an inch or so through the
gauze, will probably reduce swelling and other signs
of inflammation more quickly than gauze alone will
do. These tablets act as a depot for the supply of
salt solution.)

Failure to get good results by any of these dressings
is evidence either of incompetence in cleansing the
wound or impossibility of doing so.

During a period of severe fighting, when hundreds
of severe cases pass through a Casualty Clearing
Station in a few days, it is obviously essential to use,
as frequently as possible, a post-operative dressing
which requires the minimum of attention. A wound

122 EARLY TREATMENT OF WAR WOUNDS

efficiently treated in any of the ways indicated above
can safely be left for many days.

Bandages and splints should be applied in such a
way that the wound can be easily inspected.

Any form of dressing which requires frequent atten-
tion, whether in syringing or in renewing applications
to the depth of the wound, is unsuitable for busy
hospitals near the front. It should also be re-
membered that dread of a daily dressing, to say
nothing of the pain inflicted or the anaesthetic
required, may turn the scale against a severely
wounded man’s chance of recovery.

Many surgeons prefer to use Carrel’s method in the
after-treatment of wounds which have to be left open.
The technique of this method is so well known that
it need not be described. The disadvantages of it, as
compared with other methods used at this stage, are
the extra paraphernalia and the amount of attention
required.

REFERENCES

(1) Studies in Electro-physiology, E* A. Ramos, Consulting Elec-

trician (G, Kentledge & Sons, Ltd,), Studies in JEHectro-pcitho-
logy. Major A. White Robertson, R.A.M.C. (G. Koutledge &
Sons, Ltd.)

(2) “ A Method of Early Closure of Recent Gunshot Wounds.” By

Captain W. H, Hey, British Medical Journal , October 6th
1017.

(3) “ Report on Wound Treatment by Brilliant Green Paste.” By

Captains A, Rendle Short, J. S* Arkle, and C. King. British
Medical Journal, October 20th, 1017.

(4) “ On the Salt Pack Treatment of Infected Gunshot Wounds.”
British Medical Journal. August 26th, 1916.

(5) " A New Method of Wound Treatment by the Introduction of

Living Cultures of a spore-bearing anaerobe of the proteolytic
Group. Ike Lancet, September 22nd , 1917*

(6) “ Important Principles in the Drainage and Treatment of

U ounds.” By Major W. Pearson, The Lancet , March 24 th, 1917,*

CHAPTER V

PRINCIPLES OF TREATMENT OF GUNSHOT WOUNDS AT
CASUALTY CLEARING STATIONS

The necessity for going fully into the operative treat-
ment of war wounds is realized when one considers
that military surgery was unknown in practice to
most medical men before this war, and that many
men who have little or no experience as surgeons
are called upon, during periods of severe fighting, to
lend a hand in the operating theatres.

Reference will be made only in very short and
general terms to such matters as the administration
of anaesthetics, localization of foreign bodies by
X-rays, and the use of sera, although all these have
profound influence on the results which attend the
efforts of the surgeon.

The greatest obstacle to successful treatment of
wounds in France is the virulent inflammation which
is prone to intervene, from infection with organisms
of most noxious type which have their habitat in
the highly manured soil on which fighting takes place.
The behaviour of these heavily infected wounds has
made us realize what our forefathers had to cope with
in the worst forms of hospital gangrene, and possibly
our experience is even more bitter than theirs. High ex-

124 EARLY TREATMENT OF WAR WOUNDS

plosive missiles lacerate the tissues more than any
ancient artillery or surgeons’ knives ever did, and at
the same time force infection so deep that it develops
with more alarming rapidity and over larger extent
than ever before. It was difficult for a race of sur-
geons educated in the principles and practice of
modern aseptic surgery to accommodate their pro-
cedures to what was required in the treatment of such
cases, and, as has already been said, to shake them-
selves free from too great a trust in the efficiency of
antiseptics. In the development of modern war sur-
gery, therefore, it was inevitable that many schools
should arise, adherents to this or that antiseptic or
method of dressing ; but now, fortunately, it can be
said that all are agreed on one point, viz. that early
opening up and mechanical cleansing of severe wounds
are necessary preliminaries to any other form of
treatment. It is difficult for a tyro in war surgery
to realize how essential this thorough operative treat-
ment is, or how extensive, and in many eases seem-
ingly ruthless, it must be.

It soon became very apparent that, the earlier such
treatment is carried out, the better are the results.
Every endeavour should be made to operate before
infection has gained a hold. In other words, opera-
tion— to give the best results— must be performed in
the pre -inflammatory stage.

It is perhaps natural that one should sometimes
see a tendency to slackness in attention to essential
details of aseptic or antiseptic technique during the
performance of operations on these very dirty wounds.
No greater mistake can be made. Surgeons who get

PRINCIPLES OF TREATMENT

125

the best results are those who are most thorough
and careful with regard to rigid observance of the
technique of civil surgery, as well as to removal of
lacerated infected tissue*

Difficulties constantly occur owing to the fact that
those who have not seen cannot appreciate the appall-
ing virulence and rate of development of infections
which may take place in wounds which at first look
wonderfully clean. Avoidable loss of life and limb
will be prevented if newcomers on this field, of what-
ever standing in civil life, will take warning from
the dreadful experience to which others have had
to submit, and if they will follow the principles of
treatment which have been evolved.

It is imperative to bear in mind at all times the
state of affairs which exists in a gunshot wound, and
the objects which should be aimed at in operation*
A missile passing through a limb dissipates a con-
siderable amount of its energy in the tissues. These
tissues are struck a terrific blow, and the greater the
resistance they offer the more energy will the pro-
jectile lose in its flight. When the resistance is
enough to arrest, for example, a bullet, it is obvious
that all the energy of the projectile is spent in the
body; but it does not follow that the tissue injury
caused by a lodging missile is greater than that
caused by one which traverses the part completely.
The special gravity of u lodging 5? wounds depends
on other factors. One may say regarding all wounds,
that, given an equal resistance to its passage, the
damage done will vary as the velocity of the projectile.
This damage is not limited to the track of the missile,

126 EARLY TREATMENT OF WAR WOUNDS

which imparts its momentum to everything in or near
its line of flight, so that a radiating area of vibration
is set iip, destructive to cellular life. If the tissues
vary in density, the more compact will be driven
through the more yielding, with a shattering effect*

This is the first point of importance — the immediate
destructive effect of a projectile is not limited to its
path.

The second point is that practically every shell
wound is permeated with foreign material carrying
aerobic and anaerobic organisms, and some of the
latter thrive luxuriantly in the lacerated and de-
vitalized tissues into which they are driven.

The third point is that the organisms of u gas gan-
grene ” grow rapidly in parts which are deprived of
normal blood supply, especially in muscular tissue.

The fourth point is that the amount of infection
carried in by different kinds of missiles varies enor-
mously, This is dealt with later.

Operation should be performed in such a way that
ample access is obtained to every infected pait of
the wound, in order that all foreign matter and
devitalized tissue may be freely and thoroughly re-
moved, and that thereafter adequate drainage may
be ensured when necessary* In most regions, direct
inspection of the depth of the wound can and ought
to be procured. Treatment guided by palpation alone
is permissible or advisable only when incision would
necessitate division of such structures as the main
vessels or nerves ol a limb or would involve destruc-
tion of the function of other important parts* It is
evident, therefore, that incisions must be verv free so

PRINCIPLES OF TREATMENT

127

that sufficient inspection is possible, and, at the same
time, that these incisions must not be made in a
haphazard fashion.

In the early days of the war, before it was realized
that infection was driven into the lacerated flesh far
beyond the reach of antiseptics tlien in use, the usual
method was to clean out wounds by swabbing, irriga-
tion with lotions of various kinds and strengths, and
so forth, A recently inflicted wound might thereafter
look so clean that it was sutured completely, this
practice having been successful in civil life* The
result in practically every case was appalling. Patients
arrived at the Rase in a high state of septic intoxica-
tion, their stitched-up wounds were red and swollen,
and were in the majority of cases badly affected with
gas gangrene. The skin, although inflamed, may have
looked reasonably healthy, but the deeper parts of
the wound were invariably in a stinking condition.
Loss of life or limb was too often the penalty* Then
the edict went forth that no wounds were to be
sutured, that drainage must be established* All sorts
of drains were used, preference being given to large-
sized rubber tubes* Rut the old-fashioned method
of using them was employed — holes were made just
sufficient to admit the tube, which was often drawn
through to dependent parts, of course dragging with
it the infection from the original wound and merely
making matters worse. The condition of limbs was
such, and the general condition of the patients was
so precarious, that the guillotine amputation became
popular ; it was rapid, it provided the best drainage,
and if was therefore credited with saving lives.

■ ^

128 EARLY TREATMENT OF WAR WOUNDS

This method of amputation has almost entirely been
given up.

The behaviour of wounds widely open from the
first was little better. Inflammation of the most
virulent type frequently spread in a rapidly widening
vicious circle, in spite of well-meant efforts. But now
and again certain wounds cleaned up with striking
rapidity. A study of these wounds gave the clue to
proper treatment. The difficulty was solved to a
large extent when attention w r as paid to the condition
of the circulation in the wounded part, 1

A long time elapsed, however, before the value of
free incision combined with excision of lacerated
tissue was appreciated, and before it was realized that
gas gangrene must be treated on the same lines as a
sarcoma. Farce incision relieves tension and thereby
improves the local circulation. Excision removes
parts which have had their circulation definitely
obstructed and which will become, or already are,
affected with gas gangrene.

It was still more difficult to establish the fact that
after a properly conducted, thorough excision of such
wounds, the parts could be completely sutured and
healing by primary union obtained.

The presence of anaerobic gas-forming organisms
is so wide-spread in the soil of France, that all lacer-
ated wounds must be regarded as being infected by
them. At the risk of being thought tedious, one

1 After this book had gone to press, Capt, J. Campbell told
me of his recent work on the blood-supply of muscles, which will
be published in a short time. It corroborates in every detail
the conclusions which had been arrived at by clinical study ( Author).

PRINCIPLES OF TREATMENT

120

must insist again on the fact that the infecting material
is driven into the tissues beyond the range of imme-
diate action of any known antiseptic as ordinarily
applied. Therefore antiseptics arc useless at the out-
set, except possibly in retarding the development of
organisms in the cavity of the wound, or preventing
further infection from the outside. No one can say
how rapidly the development of gas gangrene will
take place in any particular case. One knows that
in some it may develop so suddenly and virulently
that the patient may die within twelve hours of his
injury. Therefore a great principle is established, that
a patient who requires operation shall be operated on as
soon as possible. All lacerated wounds require opera-
tion if the best results are to be obtained, and if early
closure of the wound is aimed at. If his general con-
dition is so bad that immediate operation might kill
him, every effort must be made to get the man re-
suscitated and rendered fit. for the ordeal. On the
other hand, because he is fit, perhaps very fit, there
is no excuse for postponing operation, even in the
slighter cases, except in times of great stress, when
the more serious cases must be attended to in order
to save lives. Time and again lias occurred the sad
experience of seeing a strong man admitted, appar-
ently well except for his wound, who, after a few
hours’ delay, has become so toxic that all efforts to
save bis life were of no avail. Only efficient admin-
istration of the casualty clearing station can ensure
the fulfilment of this principle.

A second principle in early treatment has reference
to the general method of operative attack on these
9

130 EARLY TREATMENT OF WAR WOUNDS

wounds. The necessity for removal of foreign ma-
terial will be discussed later. As has been mentioned
already in Chapter 1 (Gas Gangrene, page 7), it is
recognized that the bacilli of gas gangrene grow most
readily in lacerated muscular tissue which is deprived
of circulating oxygenated blood. It is necessary,
therefore, to excise all lacerated or obviously infected
muscle until definitely bleeding tissue is reached.

In the ease of a lacerated muscle or group of muscles
whose main blood supply has been severed by the
missile, this principle may entail removal of the whole
affected muscle or group. Failure to observe this
indication often results in amputation having to be
performed later, or, at best, in repetition of the excision
operation, “ Recurrence ?5 of gas gangrene usually
indicates either timidity on the part of the operator
or want of appreciation of pathological conditions
and developments, unless in cases where, for ana-
tomical reasons, complete removal may have been
impossible. Absence of bleeding in freshly incised
muscle is of far greater importance as an indication
for excision than is the absence of contraction or the
presence of so-called brick-red 5> discolouration,
which is found so frequently in the neighbourhood
of parts affected by gas gangrene. The writer has
often deliberately left such discoloured muscle, with-
out ill effect, but has always made certain that the
discoloured muscle bleeds on superficial incision. It
is, of course, apparent that such discolouration docs
not occur in the pre-inflammatory stage of wounds.
Application of the principle now enunciated will alone
guarantee eradication of the infection. The very rare

PRINCIPLES OF TREATMENT

131

cases of early systcmmic infection may be disregarded.
The situation may be summed up by stating that gas
gangrene will not develop in tissues in which there
is a vigorous circulation of healthy blood.

In carrying out such operations another point must
be borne in mind in order to avoid recurrence of the
gangrene. If the excision is made at the distal parts
first, blood-vessels supplying the tissues left behind
may be cut across in removing the proximal parts
of the wound. If any bacilli remain in the wound,
they may seize upon these devitalized parts and
produce gangrene afresh. If again, for example, the
lower half of such a muscle as the rectus femoris is
completely severed, there is great risk in leaving any
part of the detached anaemic portion. If the upper
part of the muscle likewise does not bleed on section,
owing to severance of its main vessels, it is only
tempting Providence if the whole muscle is not re-
moved. Similarly, it has been found that the only
safe procedure is to amputate, when the main vessel
of a limb {e.g. the femoral artery) has been divided
and gas gangrene has obtained a hold on the distal
parts. In dissecting out affected areas, it is both
unnecessary and risky to interfere with neighbouring
muscles whose blood supply is intact.

The bacilli of gas gangrene will develop in blood-
clot, although much less slowly and virulently. It is,
therefore, obvious that blood-clot should be removed
with meticulous care from the depth and recesses of
wounds of the soft parts and from between the in-
terstices and from the exposed medullary cavity of
fractured bones.

132 EARLY TREATMENT OF WAR WOUNDS

Primary operation should not fail in procuring
conditions which will be inimical to the development
of gas gangrene. In many cases amputation is the
only procedure which will accomplish this.

Tension interferes with normal circulation, and
should be relieved at once. Decision as to procedure
is usually easy in the case of a joint or pleural cavity.
Examination of the fluid withdrawn will most likely
reveal the presence or absence of sepsis. Positive cyto-
logical findings are important in the earliest stages.
Bacteriological examination may then be negative.
Treatment is discussed in the chapters dealing with
such injuries.

It is often difficult to decide whether tense swelling
of a limb is due chiefly to bleeding or to infection in
the depth. It is not proposed to discuss the treat-
ment of vascular injuries, but, in spite of what has
been written and said on this matter, there does not
appear to be sufficient reason why, other things being
equal, there should be hesitation to interfere with a
swelling due to haemorrhage from a wound of a large
artery, while it is looked upon as an urgent matter
to deal at once with a wound of such a vessel as the
posterior tibia!. Want of accessibility or of proximal
control by tourniquet or digital compression of the
artery involved and absence of a sufficiently skilled
operator seem to be the only valid excuses. Imme-
diate operation by suture, intubation, or ligature
should give correspondingly as good results as early
treatment of other wounds. Many young surgeons
have already demonstrated the truth of this statement,

All operations on seriously wounded or “shocked”

PRINCIPLES OF TREATMENT

133

men should he completed as rapidly as possible. The
formation of surgical teams, whose members speedily
become acquainted with each other’s capacity, has
done much to reduce the time taken in individual
operations, as well as to improve the quality of the
work done.

In the treatment of cases of severe multiple in-
juries, as many operators as can be spared, indeed as
many as can have reasonable access to the affected
parts, should be detailed to help, and obviously sur-
geons of quick judgment and rapid technique should
be chosen to deal with the more serious wounds.

Men who have suffered from shock do not stand
operation well. Routine excision operations arc often
altogether out of the question, chiefly on account of
the time they occupy, and then one has to be content
merely with procedures which relieve tension and
provide free drainage. If the patient’s vitality can
be successfully coaxed back, further operation may
be performed if necessary. In the earlier days of the
war such cases rarely survived if the operation lasted
much more than an hour. Even nowadays, with all
the available methods for resuscitation, and especially
for raising and maintaining the blood pressure by
transfusion of blood, etc., it is well to be extremely
careful not to put too great a strain on the patient’s
powers of endurance.

It is evident that, in many cases, decision whether,
when, and even how, to operate is one of great diffi-
culty. If operation is performed too early the patient
will die of shock ; if it is unduly postponed he is likely
to succumb from acute sepsis.

134 EARLY TREATMENT OF WAR WOUNDS

The systematic and collaborated investigation of
u shock-haemorrhage ” has rendered earlier decision
and earlier operation possible in the majority of cases.
The gradual education and development of interest
of all concerned in the problems* the appreciation of
the value of transfusion of blood, and especially the
appointment of one or more specialists to take charge
of the resuscitation department of each casualty
clearing station, have had much to do with the
numberless veritable resurrections which have been
brought about. To select what appears to be the
most important factor at work in these cases, one
may say shortly that the blood pressure must be
raised to and maintained at approximately normal
level. Cases of pure surgical shock are rare. The
amount of haemorrhage which different patients will
survive varies enormously. If the patient is very
exsanguine* it is obvious that he will not make much
headway without the loss of blood being made good
by transfusion as soon as possible. In some cases
also the blood pressure is so low that recourse must
be had at once to transfusion of blood or infusion of
a blood substitute.

In other cases it is well to try the “ordinary”
means of resuscitation which have been indicated in
Chapter I, If the man does not respond rapidly,
e.g. within an hour* that is* if his blood pressure does
not rise satisfactorily, blood or gum solution (6 per
cent.) must be given. The longer the blood pressure
remains low, the more difficult becomes the success
of resuscitation* the more dangerous is anaesthesia*
the more profound are metabolic changes, as evidenced

PRINCIPLES OF TREATMENT

185

by the reduction of the alkali-reserve and the pro-
duction of acidosis, and the more difficult it is to
eradicate the effect of these, super added to the original
shock, and to restore equilibrium and control to the
nervous system. Because of this loss of nervous
equilibrium, and because of these metabolic changes,
it is wise not to be precipitate in operative interfer-
ence, unless septic infection has become active*
Complete rest, especially in sleep, for an hour or two
will make an immense difference. The loss of nervous
equilibrium is evidenced by the readiness with which
patients, who have recently been resuscitated from
severe shock, will gradually slide back into a similar
or worse condition during the railway journey to
the Base.

It is interesting that the laboratory experiments
of Professor Bayliss with the use of gum solution
should be so strikingly confirmed clinically in man.
Unless gum is given fairly early, within three or four
hours, results may be very disappointing. When
haemorrhage is a prominent feature the effects of
blood infusion are always superior to those of gum.
The question of supply and expediency may settle
the question of which is to be given. Blood, whether
fresh or preserved, should be reserved for the most
severe cases* Gum should be used in the less severe
cases or as a preliminary or adjuvant to blood.

When acidosis is evident or likely to assert itself,
especially in eases of advanced gas gangrene, intra-
venous injections of bicarbonate of soda (at least one
pint of 1 per cent, solution) should be made. A
slower, although probably more lasting, effect is pro-

136 EARLY TREATMENT OF WAR WOUNDS

duced by administration of the bicarbonate by the
mouth or rectum, therefore these routes should be
chosen only in the less serious cases. In all cases
of gas gangrene the bicarbonate should be given by
mouth for several days. If the patient is troubled
by vomiting, it should be given per rectum.

The choice of ancesthetic is of the utmost importance.
The indication is again given by reference to the
blood pressure. In order of merit come nitrous oxide
and oxygen, ether, and chloroform amongst the com-
monly used general anaesthetics. The use of local
or regional anaesthesia is probably safest of all, and
should at least be combined with general anaesthesia
whenever possible. The principles of “ anoei-associa-
tion ” should be observed.

Removal of Foreign Bodies. -It is a counsel of per-
fection to say that all foreign bodies should be removed
as soon as possible. As a matter of fact, whether
they should be removed at all, and the necessity for
their early removal depends, firstly, on their size,
shape, and character, and to a less extent on the
position of the entrance v’ound. All of these deter-
mine the probable amount of infective material carried
in. Secondly, the decision depends on the mobility of
the part in which they are lodged and the probable
effect on its function. The more important the
function the greater is the necessity for early removal.

The amount of infection carried into a wound
depends chiefly on the shape and roughness of the
missile, and whether it has traversed the patient’s
clothing. An undistorted rifle bullet carries in a
negligible quantity, with which the tissues usually

PRINCIPLES OF TREATMENT

187

deal successfully. Shrapnel balls, distorted rifle
bullets, and fragments of shell practically always
carry in sufficient to cause inflammation* But shrap-
nel balls may be wiped so clean during transit
through the tissues that they do not cause infection
where they lodge. It may then quite often be ob-
served that while sepsis becomes established around
the entrance wound* the deeper parts of the track
remain or become sterile, and no inflammation occurs
around the missile itself, so that it can often be
removed ascptically through a fresh incision*

All are agreed that irregular fragments of shell,
distorted lifle bullets, and superficial shrapnel bullets
should be removed as soon as possible. Difference of
opinion exists concerning the necessity for and proper
time of removal of undistorted rifle bullets or shrapnel
balls or small pieces of shell which are difficult to
reach* The decision should really be governed by
the importance of the structure in or near which
they are embedded, and the amount of movement
which ordinarily takes place. Thus, if buried in
bone— in the condyles of the femur, for instance— a
rifle bullet almost always, and a shrapnel bullet
frequently, heals in, and may remain permanently
without causing irritation. A foreign body in the
belly of an important muscle, unless comparatively
minute, will sooner or later have to be removed. It
is dangerous to leave any kind of foreign body in
close proximity to a large pulsating vessel. Ulti-
mately it will cause secondary haemorrhage or
aneurysm. The more irregular it is in shape the
sooner will trouble occur.

188 EARLY TREATMENT OF WAR WOUNDS

The structures forming a joint lie* ordinarily, in
such close apposition during movement that there is
no room for any extraneous material. While an
aseptic foreign body, lying free in a joint, may cause
no irritation so long as the joint is kept at rest, veiy
rarely can the joint be moved to any extent without
lighting up trouble, so that removal, as early as
possible, is indicated. Much more is this the case
when sepsis is present.

Most of the foregoing remarks apply with especial
force to the brain — on the whole, of all organs, the
most important, the most delicate, and the most
susceptible to continued irritation. While small frag-
ments may cause no trouble at first, one must remem-
ber that the secondary effects brought about by the
presence of a foreign body may not declare themselves
for years after the injury, when the results of operative
interference are likely to be very unsatisfactory, even
although the foreign body is removed. Local con-
ditions, want of necessary appliances, difficulty and
danger of the operation, may of course preclude any
attempt at removal.

Greater licence is permitted, apparently, in wounds
of the thoracic organs and liver. Here, again, trouble
may accrue at a late stage from the formation of
abscesses, with sequelae of varying character and
intensity.

II suppuration has occurred around a foreign body,
common sense dictates its removal whatever be its
character.

Anti tetanic Serum, ^No matter how insignificant
the wound, every patient should receive a prophylactic

PRINCIPLES OF TREATMENT

139

dose of antitctanic scrum. If doubt exists as to
whether a dose has been given since the infliction of
the wound, the surgeon had better make certain by
giving one.

In the ease of a man wounded for the second or
third time, it is probably safer to give it in “ frac-
tional ” doses, especially if he reports having shown
any of the manifestations of serum sickness after
previous injections. In all serious wounds the ad-
ministration should be repeated every seven days
until the wound is clean and fit for closing.

If symptoms of tetanus develop, the serum should
be given in much more heroic doses than has hitherto
. usually been the case. Very encouraging results have
’ followed the administration of 60-100 thousand units,
or even more, during twenty- four hours, these large
doses should be continued daily until acute symptoms
subside, when they can be gradually reduced. The
quantity is given by all the routes recommended
(intraspinal, intravenous, intramuscular, and subcu-
taneous, especially by the latter two as the sj mptotns
subside). The reports issued by Major-General Sir
David Bruce, Colonel Sir William Leishman, and
others should be consulted.

Anti-gas Gangrene Serum. Investigations which
are being made as to tlic utility of this serum, both
as a prophylactic and curative remedy, point to its
being of value, but it is unlikely that it will permit
of any relaxation in the operative treatment v Inch
is at present considered necessary. In “ open ’
wounds in which the local circulation has not been
seriously interfered with, the serum may help to

140 EARLY TREATMENT OF WAR WOUNDS

confine the growth of the bacilli to the wound alone.
Yet the disease is so deadly, and in some cases so
insidious in its early stages, that it is unjustifiable
in any case to take the risk of trusting to drainage
alone.

X-rays.— A thoroughly reliable outfit and a com-
petent skiagraphist are essential to a surgical casualty
clearing station, even during quiet or “ peace ” times,
while in periods of severe fighting, the necessity for
a night and a day staff as well as a spare apparatus
in case of break-down, becomes evident. The eco-
nomic importance of accurate localization has been
proved over and over again in most striking fashion.
Ihis i emark applies to the immediate expenditure of
time and material, as well as to the subsequent
capacity of the patient, and the ultimate drain from
compensations on the national exchequer. Every
case of lodgment of a missile which cannot be seen
01 felt should be X-rayed, otherwise calamitous results
may follow attempts at extraction. Close co-operation
between the X-ray specialist and the surgeon must be
established in all difficult cases. For simpler cases
there should be a very definite system carried out in
all casualty clearing stations, for making and indi-
cating the localization, which should be thoroughly
understood by all surgeons who are detailed” for
casualty clearing station work. No wound of the
limbs from which the foreign body has not been re-
moved should be sutured.

Preparation and Selection of Cases for Operation —

Enough has been said to indicate the great importance
ot this part of tile work of a casualty clearing station,

PRINCIPLES OF TREATMENT

141

and no further detailed description need be given*
Ordinary cases are dealt with in a general pre-opera-
tion ward, while others suffering from the effects of
shock haemorrhage are usually treated in a specially
equipped and warmed resuscitation ward. The ad-
vantage of having selected nurses and orderlies, highly
trained in the type of work required, is very striking.
Reference has already been made to the necessity of
appointing “ shock ” teams, each consisting of a
medical officer and at least one orderly or nurse.

It is unnecessary to dwell at this point upon the
selection of cases which require immediate or pre-
ferential operation. In subsequent chapters dealing
with wounds of different parts of the body, an attempt
has been made to indicate these.

It is difficult for those who have not had experience
at the front to appreciate that infection can develop
so quickly as it sometimes does. It has already been
said that men have succumbed to acute gas infection
within twelve hours of the reception of the wound.
In a very large number it is well advanced within
twenty-four to forty-eight hours. Acute septicaemia
is frequently present within the same period, and
when due to streptococci it is particularly fatal.

To recapitulate— the rate of development of infec-
tion depends largely—

(1) On the amount and virulence of the infection.
The amount can be roughly estimated at an early
stage by the size and character of the foreign bodies
and by the extent of general soiling of the wound ;
immediately after the injury the virulence cannot be
estimated.

142 EARLY TREATMENT OF WAR WOUNDS

(2) On the extent of the injury and the amount of
laceration present.

(3) On the integrity of the blood supply which is
affected by the injury or other mechanical causes, by
tension in the wound, by shock, haemorrhage, etc.

It is impossible to give accurate directions as to
the treatment of any particular case. Experience
alone will convince most surgeons how powerless they
are to help many patients, while others again rally
rapidly. The purely operative treatment of the wound
is usually the simplest problem.

CHAPTER VI

OPERATIVE TREATMENT OF WAR WOUNDS

Before categorically describing operative technique,
emphasis must again be laid on those fundamentals
which dominate the method and extent of attack
upon war wounds, namely, the character and size of
the missile, the time since the wound was inflicted,
and the condition of the patient when first seen by
the surgeon.

(!) Character and Size of the Missile, — These arc
the most important factors, for on them depend the
amount of infection carried into the wound at the
moment of injury. The mere size of a wound does
not determine the difficulty of eradicating infection,
A large explosive exit caused by an undistorted rifle
bullet is comparatively easily rendered sterile. In-
fection of its surfaces is secondary and at first purely
superficial , On the other hand, a jagged piece of shell
carries in a large amount of infective material and
forces it deeply into the walls of the track, so that,
even though only small superficial wounds are seen,
very extensive incision and excision may be required.
It is in dealing with this type of wound that experience
and judgment are pre-eminently of value.

(2) Time since Infliction of the Wound. — It is un-

143

144 EARLY TREATMENT OF WAR WOUNDS

necessary to revert to the fact that, taken alone, the
best time for radical operation is before infection has
had time to develop ; but other factors render it
necessary that the time, which has elapsed since in-
fliction of the wound, shall be considered in conjunc-
tion with the virulence of the inflammation* Gas
gangrene demands prompt and extensive operation
based on the principles already indicated, irrespective
of the time interval since the injury. In other cases,
however, where several days may have passed, during
which men have been lying out on the battle-field, the
question of operation is approached from a special
standpoint. Conditions of circulation and drainage
have allowed the natural resistance of the patient to
prevail, and such as arrive at the casualty clearing
station alive, having overcome the tendency for in-
flammation to spread, may be suffering merely from
the effects of retention of pus* Here it is wxll to
defer, if possible, even comparatively trivial opera-
tions until the patients have been cared for thoroughly.
They are usually suffering from starvation, so that
the administration of a general anaesthetic (especially
chloroform and, to a less extent, ether) may precipitate
severe acidosis. Unless the wound is of such a nature
that complete excision en masse can be done, any
interference is to be deprecated further than removal
of foreign or sloughing material and the establishment
of drainage of pockets in which retention is occurring*
If a man has been seriously wounded, he survives for
such a long period only if his wounds have been freely
laid open by the missile, and only if the local circula-
tion around the wounds remains good. It is rare to

OPERATIVE TREATMENT

145

see men with serious shell wounds of other types
survive without surgical treatment for a period long
enough to allow the formation of granulation tissue.
They die on the field within a very few days, or else,
when picked up at the end of that time, too often
are found to have such a degree of toxaemia that the
strain of transport proves more than they can bear.

(3) The General Condition of the Patient, — As has
been stated in Chapter IV, many patients are in
such poor condition from loss of blood and shock
that only the minimum of interference compatible
with what is necessary to save life is possible. Every
endeavour must be made to prevent unnecessary
loss of blood during operations. Pneumatic tour*
niquets arc to be recommended instead of the
ordinary pattern, because their constricting pressure
can be accurately regulated, so that it just stops
the circulation without deleteriously affecting tissues
whose vitality may already be seriously threatened.

For purposes of discussion of operative treatment,
wounds may be divided into three groups*

I- Simple Perforating Wounds in which the Track
is of about the same Diameter as the Skin Aperture.—
The most frequent example of this group is the
through and through wound caused by a rifle-bullet
traversing at long range the soft tissues of a limb,
where the apertures of entry and exit are small, the
damage to muscle is slight, and there is no lesion of
large vessels or nerves,

II. Wounds in which the Destruction of Skin
and Superficial Tissues is of greater Extent than the
Destruction of Deeper Structures, — In such wounds

10

146 EARLY TREATMENT OF WAR WOUNDS

gutter ” wounds, explosive exits, superficial lacera-
tions, avulsions) the deeper parts are more or less
exteriorized, and what is required is the excision of
all damaged tissues, in order to attain the ideal of
an open wound with a living uninfected surface,

III. Wounds in which the Skin Aperture is small in
relation to the Extent oi Damage inflicted on Deeper
Parts, —This group includes the majority of all wounds,
and may be divided into (a) Lodging wounds, and
(ft) Traversing wounds.

Except when injury to important structures in
other types demands immediate attention, these are
the wounds which most urgently call for operative
treatment.

OPERATIVE TECHNIQUE

Sterilization of Skin,— The skin should be washed
with soap and water around and close to the wound.
If if is heavily caked with mud, a soft scrubbing-
brush should be used to accelerate cleansing. Hairy
parts should be shaved.

During the skin-cleansing process the wound should
be covered with an absorbent swab, so that discharge
may not escape and soil the skin. In many cases
the wound should first be packed lightly with gauze
wrung out of picric acid solution (3 per cent, in
methylated spirit) or of the more deeply staining
solutions described later under (6), Dry the skin
and finally rub it over with a swab dipped in the
picric acid solution.

All parts to be covered by the bandage which fixes
the dressing should be dealt with in this way. In a

OPERATIVE TREATMENT

147

limb the whole circumference should be cleansed.
Hurry and lack of method in cleaning the skin will
result in failure to achieve sterility.

In the ease of a wound belonging to Group III.
the direction of the track should previously be ascer-
tained, preferably when possible with the finger, a
search that is often aided by moving the limb in
different directions. The limb must be placed in the
position it occupied when struck by the missile before
a finger, forceps, etc,, can be passed along the track.
During operation, especially in the neighbourhood of
joints, the limb should be fixed in that position,
(Compare also page 156, para 7,)

The operative treatment of wounds of soft parts
alone will be discussed now. The more elaborate
measures necessary when fracture co-exists will be
described in later chapters.

Excision by a sharp scalpel is always preferable to
excision by scissors. The wound should be treated
as much as possible like a sarcoma. When scissors
are used, septic material may be carried along the
edges of the blades as they close, and the freshly cut
tissues are thus immediately infected. The success
of an excision operation is thereby imperilled. For
this reason it is imperative that expert cutlers should
be on the staff of a casualty clearing station. Sixty
to one hundred scalpels may be used every day during
very busy times. A sharp scalpel is almost as im-
portant, from the economy point of view, as a good
X-ray picture; indeed, in some eases, it is even more so.

148 EARLY TREATMENT OF WAR WOUNDS

(1) Treatment of the Severer Types of Group I. —

The majority of these wounds requires no operative
treatment, or, at most, a narrow excision of the
wounds in the skin and fascia, followed by suture.
If no excision is made, the surface wounds should,
after cleansing, be rubbed with a little Bipp or other
antiseptic paste.

If there is great tension in the depth owing to
haemorrhage, or if paralysis, indicating severance of
a motor nerve, is present, immediate operation ought
to be done, either to ligature the bleeding vessels or
suture the torn nerve.

Small through -and- tli rough surface wounds aie
sometimes accompanied by great destruction- of
muscle. The amount of destruction depends usually
upon the state of the muscle as regards contraction
at the moment of impact. If the muscle is tense, its
torn fibres tend to spring apart like broken fiddle-
strings. Such cases belong to Group III. When time
permits, such wounds should be laid open, clot cleared
away, and suture of the torn muscle carried out, fol-
lowed by complete closure of the usually aseptic wound.

(2) Excision of Gutter Wound (Group II).— Small
wounds of this nature can always be excised under
local anaesthesia by infiltration of the tissues sur-
rounding the wound. In larger, deeper, and more
irregular wounds considerable care may have to be
exercised in making the injections so that all parts
of the wound are anaesthetized. If adrenalin be
added to the anaesthetic solution, bleeding becomes
negligible. On the whole, in very large wounds, it
is better for beginners to use general anaesthesia.

OPERATIVE TREATMENT

140

A tourniquet should be used whenever possible, so
that swabbing is reduced to a minimum.

The raw surface of the wound is dried and thor-
oughly soaked with strong picric acid or iodine solu-
tion {ID per cent, in methylated spirit)* Excess is
absorbed by a swab. This lias the effect of dessicating
the wound. A small wound may be cauterized with
the actual cautery. The wound is repacked with
sterile gauze. It is then completely excised en masse
by a series of elliptical or lemon-shaped cuts which
should not be less than £ in. from the edges and deep
surfaces. It is advisable to prepare one side of the
ellipse completely before cutting into the other, by
incising the .skin and deep fascia together, and then
deepening the cut rapidly until all the wound is
undermined. This incision is then packed with gauze.
The incision on the other side of the wound is then
made in the same manner, completing the ellipse.
A wedge of tissue is thus excised, enclosing the wound
cavity which is not opened at any part. A very
sharp scalpel makes the operation comparatively easy.
The use of a finger in the wound sometimes enables
one to cut clear of pockets which would otherwise
be opened. If this is done, the same finger should
be kept in the wound until the excision is completed ;
it is then disinfected or the glove changed. The ends
of the ellipse may be caught by forcipes and steadied
by an assistant, who makes very slight traction in an
upward and outward direction. The forcipes (tissue
or artery) are necessary only during the second half
of the excision. They should catch up muscle as
well as skin. While the deeper structures are being

150 EARLY TREATMENT OF WAR WOUNDS

cut on either side of the wound, the outer surface of
the flap may be caught by forcipes and steadied by
an assistant, who should remember that it is very
easy to tear open the cavity of the wound. If possible,
no swabbing should be done during the excision ; and,
if it is necessary, great care must be exercised that
infection from the original wound is not transferred
to the freshly made one. All bleeding is carefully
controlled.

The wound is sutured in such a way that no dead
spaces are left. This may entail the use of buried
sutures, preferably of catgut. All sutures should
catch up lightly “ the layer next below. 55 If mistakes
in technique have been made, tight sutures, whether
deep or superficial, may be the cause of gas gangrene
by interfering too much with the blood supply of the
tissues which they draw together. Shallow wounds
can usually be closed by a single row of sutures, which
should just emerge in the depth of the wound as they
cross from side to side. In some eases the part may
have to be specially relaxed and fixed in the relaxed
position during suturing and the early days of con-
valescence.

Mastisol varnish dressing is recommended strongly
(see page 165). Application of a thick layer of cotton
wool, a firm *broad bandage, and possibly a splint,
completes the operation.

If an important vessel, nerve, or other structure
is exposed and cannot be cleaned properly, or if the
original wound cavity has been entered at any part
during the operation, primary suture should not be
done without previous careful antiseptic washing of

OPERATIVE TREATMENT

151

the fresh wound surfaces and possibly smearing with
a paraffin antiseptic paste. In more doubtful cases
the wound may be packed or treated by Carrel’s
method in preparation for delayed primary suture in
two or three days’ time*

(3) Excision of traversing Wound with Explosive
Exit (Group II)*— If the wound has been caused by
an undistorted conical bullet, so that little or no
septic material has been carried through the puncture
wound of entrance, and if the soft parts only have
been injured, the lacerated gaping part of the wound
may be excised and sutured, as lias been described
under (2)* The narrow part of the track may be
disregarded*

If the wound lias been caused by a shrapnel ball
or piece of shell, the whole track must be excised or
otherwise dealt with. (See under 4 ( b ) and 5. )

(4) Tunnel Wounds (Group III)*

(a) If superficial, draw a strip of gauze, which com-
pletely fills the wound, through the tunnel, and excise
the whole track as in (2).

(5) If traversing the depth, when no suspicion of
gas infection exists, and if it is thought that the
circulation around the track is good, the tunnel may
be cleaned by passing a forceps along it and drawing
through a suitably thick strip of gauze which will
sweep out gross dirt and blood-clot* Successive strips
of gauze are drawn through, in the same direction.
On no account should sawing motions be made with
the gauze in the wound, as this will simply rub
sepsis deeper. Another strip of gauze, considerably
narrower than the diameter of the tunnel, and

j

152 EARLY TREATMENT OE WAR WOUNDS

impregnated with an antiseptic paraffin paste, is
then drawn through and left in situ. It can often
be removed safely in a couple of days, and the walls
of the wound pressed together by dressing pads and
bandages.

(c) In other cases the wound should be treated as
in (5).

In times of sever e stress many other types of wound
must be treated as indicated in (6), but only if gas
gangrene has not declared itself. If done carefully,
the procedure will, in many cases, cause only mo-
mentary pain, so that an anaesthetic may be dis-
pensed with. In cases which require it, the primary
anaesthetic period of chloroform or ether, which lasts
about a minute, is usually sufficient. The onset of
this period is found by making the patient hold an
arm vertically as long as he can, while anaesthesia
is being induced. When the arm drops he will not
be capable of feeling pain, and such short operations
as opening an abscess, avulsion of a toe-nail, or the
procedure just described, can be carried out. If the
anaesthetic has to be continued, the ' 1 struggling 55 or
excitement stage will be stimulated at the end of
this short analgesic period.

Tunnelling or lodging wounds of or near the buttocks
should be treated with special consideration and thor-
oughness. These were particularly dangerous wounds
before treatment by free excision was adopted.

(5) Traversing Shell Wounds (Group III). — Entry
and exit wounds of the skin and deep fascia should
be excised by elliptical incisions. Usually it is un-
necessary to cut away more than £ inch of skin all

OPERATIVE TREATMENT 153

round. As a general rule, the area of skin excised
varies inversely with the skill of the surgeon. If
sufficient access is not provided through the super-
ficial excision— and it is only rarely that this is the
case— the ends of the ellipse should be prolonged frecl>
so that the sides of the wound may he easily retracted.
These incisions should run in the direction of the
main track or pockets of the wound which have pre-
viously been ascertained. After the freshly incised
superficial parts have been retracted, the lacerated
muscular tissue in the depth of the wound is seized
with tissue forceps and excised cleanly and systema-
tically. Care must be taken, as far as possible, to
cut in healthy tissue. If the knife is soiled by contact
with lacerated muscle, it must at once be cleaned or
preferably replaced by a sterile one. Attention is
drawn to this here, as it is more likely to occur in
this type of wound, but obviously the same precau-
tion must also be taken in excision of other wounds.
Working from both ends, the wound should be excised
en masse if possible. This is extremely difficult to do
in many cases, so that the inferior “ piece- meal ”
excision must be resorted to. In all cases the indi-
cations for the prevention of gas gangrene, given in
Chapter IV, must be followed.

It is evident that, if treatment on these indications
is to be successfully carried out, it is of the greatest
importance that incisions are made sufficiently free
to allow thorough inspection of the depth of the
wound. Inadequate incisions spoil work in another
way. They tempt the operator to use forcible and
prolonged retraction which bruises the tender muscle

154 EARLY TREATMENT OF WAR WOUNDS

fibres and renders them a prey to saprophytes which
may be left in the wound.

A very useful procedure for beginners is to stain
the dead or dying tissue along the track by injecting
2 per cent, solution of methylene blue or § per cent,
solution of brilliant green. This can best be done
by passing a catheter or other rubber tube along the
track and squirting the solution through it*. All
stained tissue at least should be excised,

(6) Lodging Shell Wounds (Group III).— These arc
dealt with on the same lines as described in (2) and
(5), according to the depth of the retained fragment.
The fact that there is no exit wound to indicate the
direction of the track may cause a little difficulty*
because fragments are sometimes deflected by resis-
tant tissues before they finally come to rest* so that
the line drawn between the entrance wound and the
site of lodgment ascertained by X-rays is by no means
straight. This is found most frequently when a
shrapnel ball impinges on bone. Every effort should
be made to follow and excise the walls of the track
in its whole extent. Here again the advantage of
long incisions, which allow easy inspection, as opposed
to short ones, which compel exploration to be done
mainly by touch, is very manifest. In any case, it
is sometimes difficult to follow the deeper parts of
the track after excision of the more superficial parts.
It will be found that if the limb is moved slowly so
that the deeper planes of muscle assume different
relative positions, the track through them will come
into view. A finger can then be gently insinuated
along it and may feel the foreign body, when a probe

155

OPERATIVE TREATMENT

or forceps can be passed along the finger and left in
the track as a guide. The limb should be fixed in
the new position till the operation is completed*

The bed in which the foreign body is lodged requires
special attention. It happens far too frequently that
the operator extracts a fragment, holds it up trium-
phantly, and considers that all that is required has
been done. But pieces of clothing, mud, etc., which
have been carried in front of the metal fragment are
equally important as factors of infection. The tissues
in the neighbourhood are possibly the most heavily
infected of all — they have been rendered anaemic by
the pressure of the foreign body, and probably form
a focus from which gas gangrene will spread. The
area must therefore be freely inspected, cleansed of
all foreign material, and all lacerated or suspicious
tissue carefully cut away.

It is sometimes found necessary to make a counter
incision, either for the purpose of obtaining easier
access to the foreign body or for drainage. Such
counter openings should be free, especially if they
are made for extracting a fragment of shell.

While primary suture can be carried out in a large
number of these wounds, it must be remembered that
the extra manipulation and the piece-meal excision,
which is so often compulsory, as well as the often
widespread sepsis which may be present, make pri-
mary union uncertain. The amount of success in
obtaining this forms a very good index of the ability
and judgment of the surgeon. The real expert can
afford to suture more wounds and at the same time
to do without extraneous help from antiseptic pastes.

156 EARLY TREATMENT OF WAR WOUNDS

lotions, drainage, and so forth, while the beginner
should leave more wounds open for delayed primary
suture, and invariably invoke the aid of these ex-
traneous helps either singly or in combination.

{7) Multiple Wounds.—' These require mention again
on account of their frequency, and by reason of the
special problems they present. As has been stated,
the condition of the patient often will not allow the
operator to deal with each wound as thoroughly as
could be wished. The first thing at operation is to
determine the general direction of the fragments of
projectile. Search will usually reveal a graze, a gutter
or tunnel wound, which gives a clue to the course
of the others. It then remains to decide which wound
should be dealt with first and most thoroughly. Ex-
cluding fractures and penetration of the body cavities,
lodging wounds of the buttocks, thighs, calves, shoul-
ders, and root of the neck should receive preference.

It frequently happens that multiple wounds from
lodging bomb splinters arc crowded so close together
that excision of each separately is not advisable. The
patients are often in such bad condition that haste
is necessary, A single long incision down to the deep
fascia, followed by rapid undermining of the subcu-
taneous fat to beyond the wounds, will usually reveal
the extent of damage to the muscle and facilitate
quick decision as to what is best to do. In such cases
gas gangrene is apt to develop very quickly. The
fragments of bomb cause considerable churning where
they finally come to rest. If they arc fairly super-
ficial, free excision of the affected muscle is usually
advisable. Such cases very rarely permit of primary

157

OPERATIVE TREATMENT

suture. If the fragments have penetrated deeply or
traversed the greater part of a limb, amputation is
p r acti ca 1 ly eo m p u Iso r y .

Haemostasis* — At the conclusion of all these ex-
cision operations, great care should be devoted to
this, because, if blood is allowed to accumulate in
the depth and crevices of the wound, the development
of sepsis is favoured. All visible vessels should be
ligatured, even although they do not bleed when
exposed. It often saves much time, when dealing
with vessels adjacent to bone or fascial planes, if the
ligature is threaded on a rounded needle and a small
part of the unimportant tissues around the vessel
caught up by it and tied in with the vessel* This
prevents slipping of the ligature*

REMARKS CONCERNING EARLY EXCISION AND
SUTURE OF WOUNDS

Excision of infected wounds, whether of soft tissues
only or when accompanying fractures, was practised
by the writer for many years before the war, and
was deliberately applied in the treatment of war
wounds in November 1914. The first case was that
of a German soldier, who had a filthy, very deep
gutter wound of the posterior axillary fold on the
right side, sustained three days before operation*
Excision and suture was followed by perfect primary
healing* A similar wound of his right arm, which was
cleaned merely by excision of the sloughing parts, left
open, and packed, furnished an instructive contrast.

It was a natural sequence that a principle in treat-

/

158 EARLY TREATMENT OF WAR WOUNDS

rncnt, which could be applied with such success in
war wounds of soft parts alone, should be extended
to wounds involving all kinds of tissues. It has
been abundantly proved during the war that the
measure and rapidity of success attendant on treat-
ment of all wounds, especially of the more complicated
types (skull, knee, long bones, chest), depend on the
efficiency with which removal of infected tissue is
carried out. Excision en bloc guarantees most cer-
tainly that healing per prim am will follow primary
suture. Piece-meal excision is, unfortunately, too
frequently compulsory, and is bound to be followed
by a large proportion of failures.

If is curious and somewhat inexplicable that the
technique laid down for treatment of these compli-
cated types of wounds should have been so widely
accepted as correct, although only after considerable
delay, while that for the simpler types was neglected
by the majority of consultants and surgeons in France.
The cart was placed before the horse. Several British
anti Colonial surgeons, however, practised the method
in the early days of 1915, C1) and have continued to
use it with increasing success. It was not blessed by
the general body of English-speaking surgeons, how-
ever, until it was discovered that our French confreres
had also satisfactorily demonstrated its advantages.

While it is obvious that the best results should be
obtained from operation in the pre -inflammatory
stage, before infection has gained a firm hold on the
tissues, yet it must be remembered that excision and
immediate suture was done in those early days of
the war on wounds which were two to four days old,

V3

OPERATIVE TREATMENT

159

when infection had become established, in some cases
in a very acute degree. Results showed that in
capable hands healing b}^ first intention was obtained
in over 90 per cent, of the cases. In one series re-
ported (scalp wounds), in which cases showing stitch
suppuration were regarded as failures, 400 excisions
out of 412, healed by perfect first intention, (2)

The sudden popularity of primary excision and
suture of wounds, which developed in 1917, led to
abuse of the method in too many instances. It seems
absurd, and ought to be superfluous, to have to say
that wounds must not be sutured completely unless all
gross infective material is previously removed. A care-
ful, thorough excision of superficial parts is neutralized
if infective material and foreign bodies are left in the
depth of the wound. Suture of such a wound in a
limb has led to subsequent amputation, revealing the
foreign body and the unpardonable sin of the surgeon.

Although during “ peace ” times, when patients can
be kept for observation for several days, primary
suture of large wounds or amputation stumps is
attended with gratifying success, yet in periods of
active fighting it is not advisable to carry it out unless
one is very sure of having procured asepsis. Most of
the patients cannot be retained and left at rest in
bed. The stress of transport rouses any infection
which may have been left, and which would likely
have been dealt with successfully by the tissues under
favourable conditions of rest. These remarks apply
especially to wounds of the limbs and trunk in regions
which cannot be absolutely fixed by splinting. Again
it must be said that the success with which sutured

I

160 EARLY TREATMENT OF WAR WOUNDS

cases travel to the Base immediately after operation
is an excellent criterion of the capacity of the surgeon
who has operated on them, and proves that the use
of the scissors instead of the scalpel endangers success.
Proper technique and sound judgment are essential.

Primary suture should be done in all cases when
the essential conditions are fulfilled, unless pressure
of work makes it impossible to give the extra time
necessary. The fact that restoration of function,
when that is possible, occurs far more quickly and
certainly after careful preparation and primary suture,
makes this procedure more than desirable. In some
wounds “ open 55 treatment means simply delay in
healing and subsequent impairment of function* In
other types it may mean grave risk of death or com-
plete loss of function* Certain cases should always
be closed as a routine, for example, wounds of the
joints, most of which can be absolutely fixed and
supported during transport, wounds of the brain and
i ts cove r i ngs , chc st , an d a bd om i n al w ou nds * Won n d s
of the knee must usually be kept at the casualty
clearing station for several days ; those of the brain,
chest, and abdomen perhaps for several weeks.

The following paper on this subject was published
by the author in the Journal of the Royal Army Medical
Corps in June 1915, and in the British Medical Journal
August 28th, 1915.

“ Treatment qe Gunshot Wounds by Excision
and Primary Suture

“ The number of cases to which this treatment is
applicable makes ample justification for attempting

161

OPERATIVE TREATMENT

to make the method more widely known and popular*
I began this method of treatment of certain lacerated
4 furrow ’ wounds in November 1014, and was so
impressed by its utility that I have since then urged
that it should be carried out whenever possible. The
advantages claimed for its use are :

** (1) Healing by first intention is assured in the
vast majority of properly selected cases,

(2) Much time is thereby saved. Some wounds,
which would otherwise require months to heal, are
soundly united in the course of ten to fourteen days.
The soldier is thus available for duty again at a much
earlier date.

“ (3) The amount of attention required to be given
by the medical officers, nursing sisters, etc*, is greatly
reduced#

“ (4) Much pain is avoided.

u (5) The amount of dressings required is reduced
to a minimum and in this way expense is lessened.

“ (6) Complications which may arise from the
presence of a septic wound are avoided.

“ (7) A more sightly scar is obtained,

“ (8) Because of the absence of contraction which
would accompany formation of a large cicatrix, there
is less impairment of function in the part concerned,

44 (9) In the case of head injuries, excision of the
wound, especially in some, apparently trivial, injuries,
provides a means of ascertaining, with greater cer-
tainty than by any other method, whether depressed
fracture and injury to the brain coexist.

4 4 Healing by first intention may be procured in
practically all cases in which the surfaces of the new
11

162 EARLY TREATMENT OF WAR WOUNDS

wound can be brought into accurate approximation
without much tension. In rare cases, when the wound
is deep, approximation in the depth has to be dis-
pensed with and drains are introduced for a short
period, until one is assured that aseptic healing will
occur. In some cases it is necessary to adjust and
fix the parts of the body adjacent to the sutured
wound so that the fullest relaxation is secured.

“ The mere length of a wound is no bar to operation.
Some very long wounds have been excised. A missile
may inflict what resembles an incised wound and,
because dividing the tissues at right angles to the
line of their greatest tension, may, owing to the
contractility of these tissues, cause a large gaping
wound. In such eases there will be but little tension
when sutures are inserted and tied, if too great a
mass has not to be excised. One can test roughly
what the amount of such tension will be, by attempt-
ing to push the surfaces of the wound together.

“ It is not necessary to wait until the wound is
surgically clean ; in fact, in most cases the sooner
the excision is made the better. The wound will
probably be soundly healed in a shorter time than
it will take to clean. During the 6 cleaning ’ process
the adjacent parts become so softened that sutures
do not hold well. Only when a large 4 bank ! of in-
flamed tissue surrounds the wound is immediate
excision inadvisable on account of the septic condition
of the wound. In such cases it is probable that
organisms have penetrated to a considerable depth
and will cause trouble when the tissues invaded by
them are subjected to the pressure of sutures. By

OPERATIVE TREATMENT

163

vigorous salt-pack treatment such wounds are usually
rendered suitable for excision in twenty-four to forty-
eight hours. Other contra-indications are the pre-
sence of marked pocketing in the wound and the
exposure of vascular or nerve trunks in the depth or
of bone which it is inadvisable or impossible to remove.

“ Certain bony prominences, such as a vertebral
spine or the edge of the acromion process* may be
capable of removal with, the other infected tissues.
The presence of pocketing in a wound is very im-
portant, If part of such a pocket, or, indeed, if any
septic focus be left, the operation will probably prove
a failure,

4 6 The technique is therefore very important. The
operation can usually be done under infiltration
anaesthesia of the neighbouring parts. It is well to
add plenty of adrenalin to the anaesthetic solution
so that haemorrhage during the operation is avoided.
Accurate haemostasis is important for success*

44 The parts around are shaved and disinfected very
thoroughly. The wound is wiped out, dried, and
packed with gauze.

14 For disinfecting purposes in these cases I favour
the use of very strong iodine solution (5 to 10 per cent,
in spirit or ether). (I now use picric acid solution
of similar strength.) This is painted thoroughly into
every part of the wound and over the surrounding
skin for a considerable area. It has the effect of
drying the surface of the wound in a remarkable
manner. The strong iodine is wiped off the skin
with spirit or ether at the end of the operation,
t4 The skin close to each extremity of the wound is

z^f

164 EARLY TREATMENT OF WAR WOUNDS

caught up by a tissue forceps or loop of thread and
slight traction is made in a direction away from the
centre of the wound at an angle of about forty-five
degrees with the sound skin* The whole wound is
then cut away cu viassc (skin, flesh, and, if necessary,
bone) at a distance of about one-third to half an inch
from the raw surface. Care must be taken that
pockets or general surfaces of the wound are not
cut into during this procedure. Bony prominences
are removed along with the soft parts by dividing
them with bone-pliers, gouge-forceps, or chisel. If
the wound is deep it is sometimes of advantage to
insert the finger into the wound as a guide to where
the tissues must be divided.

“ A very sharp scalpel is invaluable. Cutting out
the wound in pieces makes success precarious.

“ The new wound surfaces should now be washed
out with saline solution and packed with gauze, and
the surrounding skin wiped free of blood or discharge.
Fresh towels, fresh instruments, and, if the wound
has been handled, fresh gloves should now be used.

“ The wound should be closed by wide sutures
which underrun its floor so that no dead spaces are
left. It may be necessary to suture in layers. If
so, the suture of each layer should include some of
the tissue of the deeper layer. The skin should be
accurately approximated by a few fine sutures.
Further relaxation sutures arc not often necessary.

“ The following dressing should then be applied.
The line of sutures and the adjacent skin for several
inches should be painted with a wound varnish, of
which mastic, dissolved in some rapidly evaporating

165

OPERATIVE TREATMENT

solvent, forms the important part (40 to 50 per cent.).
When the varnish lias become 6 sticky/ a covering
of gauze, at least two layers thick, should be stretched
tightly and smoothly over the sticky area, gently
patted down, and cotton- wool and bandages applied
fairly firmly. If it is desired to inspect the wound
at any time, after removing the bandage and wool,
the top layer or layers of gauze should be peeled off
by traction at right angles to the surface, the layer
next the skin and wound being at the same time
retained by the other hand. Perfectly satisfactory
inspection can be made through the single layer of
gauze. The loose edges of the gauze should be neatly
trimmed. In many cases no further dressing is re-
quired until the stitches are to be removed. The
final layer of gauze is then peeled off.

4i If fine catgut sutures have been used for the
skin, it is often found that the knots come away with
the layer of gauze, the deeper parts having been
digested. A fresh application of the mastic varnish
and gauze should then be made and left until the
wound is firmly healed.

“ The varnish should on no account be painted
over the gauze after it has been applied, otherwise
the gauze cannot be peeled off as described. The
varnish and gauze dressing is important for success.
It is the best I know. It gives wide support, relieves
tension, and prevents any dragging on the stitches.
These factors are of great value in preventing stitch
abscess.” (See page 212.)

“ Delayed Primary Suture This, when anatomi-

166 EARLY TREATMENT OF WAR WOUNDS

cally possible, is performed if, after two to four days,
the wound is found to be free from inflammation.
Sueh wounds should be dressed for the first time in
the operation theatre, so that delay and possible
preventible infection does not occur between the
dressing and suture. “ Cultures 55 may be taken from
the surface of the wound.

The presence of haemolytic streptococci in a wound
contra-indicates suture. If their presence is detected
only after the wound has been sutured, it becomes
imperative to open up the wound entirely and imme-
diately when the slightest symptom of local or general
sepsis is apparent.

Secondary Suture. — The operation of “secondary
suture ” is performed for such cases as can be closed
only after granulation of the wound surfaces has
occurred and all sloughs have separated. Many
surgeons have relied on the “bacterial count ” in
smears from the crevices of the wound as an indica-
tion of when it is safe to close sueh wounds. It
may be looked upon as heresy to say that, in the
great majority of cases, such examinations arc
unnecessary and, unless carried out with the greatest
care and skill, are unreliable.

Fixation and support of the wounded part must be
secured, in mild cases by proper bandaging, in severe
cases by splints, even although soft parts only are
affected. Efficient fixation in an appropriate and
comfortable position will limit effusion and consequent
swelling as well as suffering for the patient. Soft
parts must be prevented from sagging, especially
where deep lacerated wounds accompany fractures

OPERATIVE TREATMENT

1G7

of such a bone as the femur. In these cases support
is best provided by suitably shaped gutters or slings
of perforated zinc, properly padded and covered with
waterproof material, which arc placed under the limb.
The edges of the gutter arc bent over the side-bars
of the Thomas’s splint, which is now universally used.
The slings should be arranged so as not to interfere
with easy access to the wound or with drainage*
Clean ones are substituted when required. The slings
should be reinforced, especially during transport, by
suitably sized pieces of Gooch’s splinting*

Drainage and Kind of Drain. —The primary object
of drainage is, of course, to prevent accumulation in
dead spaces of fluids which will form favourable media
for the growth of pathogenic micro-organisms, and
which also, on physical grounds alone, will prevent
or delay healing by keeping the tissues from adhering.
However, if the dead space left after suture is not
large, and can be obliterated by suitable bandaging,
if the effusion is likely to be small in amount, and if
the wounded part has been rendered aseptic, there is
no necessity for drainage. In certain cases also,
when, for example, slight infection of the knee-joint
or brain has been found, the presence in the affected
part of a foreign body, such as a rubber drain, and
still more a glass or metal one, will probably allow
sepsis to gain a firm hold, especially in parts bruised
by the drain — the very thing the latter is meant to
prevent. It seems absurd to take a deal of trouble
to remove one unyielding foreign body and forthwith
to insert another, unless for very definite and well-
considered reasons. Such drainage after thorough

108 EARLY TREATMENT OF WAR WOUNDS

mechanical cleansing of a wound can usually be dis-
pensed with, and should be avoided when possible.

Drainage of large wounds is effected best by in-
serting a fairly firm pack of plain or, better, paraffin
impregnated gauze. In the case of the antiseptic
paraffin pack, discharge finds its way readily first
between the walls of the wound and the pack and
later into the pack itself.

The more delicate or highly organized a structure
is, the more likely is it that damage will be caused
by the introduction of a drain, especially of a rigid
one. Experience has shown that, if drains have to
be employed, the principle of introducing them
“ down to but not into ” the important cavity or
injured structure is sound. It matters not whether
brain, shattered bone, pleural or synovial cavity has
to be drained — the principle holds good. This refers
to the preventive function of a drain which is used
when infection has not yet obtained a firm hold.

When infection is really well established, and is
already causing suppurative encephalitis, osteomye-
litis, or synovitis, the matter is more difficult and
requires much judgment. The presence of decom-
posing blood-clot, loose purulent lymph-clot, or even
offensive pus in a joint, although accompanied by
swollen and injected synovial membrane, does not
mean that the joint is inevitably doomed to destruc-
tion. Many brilliant results have been obtained,
even in the knee-joint, which was thought to be
particularly vulnerable, by cleansing the cavity thor-
oughly of foreign bodies and purulent contents, wash-
ing out with appropriate solution, and then draining

OPERATIVE TREATMENT

109

for twenty-four hours or so by a tube which reached
down to but not into the hole in the synovial cavit}^
In some cases— and this depends a great deal on the
character and position of the wound left after opera-
tion — it seems to be an equally efficient method merely
to leave the wound open, and to protect it from
secondary infection by an antiseptic pack. Absolute
fixation of the joint during transport after such
operations seems indispensable to success. It must
be said, however, that the treatment advocated in
septic joints by Belgian surgeons (Willems) of making
the patient carry out repeated active movements of
the joint, as soon as possible after operation, so as
to force out septic material through open incisions,
although in direct opposition to previously accepted
ideas, has been followed by some impressive, favour-
able results, Tlie jars and vibrations experienced on
a railway journey may be the cause of the lighting
up of sepsis in these cases just as much as the passive
movement so much objected to by our Belgian friends.
(See chapter on Joint Wounds.)

Drainage of the brain, when abscess has formed
round imbedded bone or foreign body, is a very
difficult matter. Rigid drains are particularly harm-
ful to the brain. This is especially true if holes are
cut in them, because the intracranial pressure forces
even normal brain through the holes or the end of
the tube, and, moreover, the constant friction of the
pulsating brain against the hard foreign body must
have a bad effect. The most satisfactory drain in
this case seems, on the whole, to be a piece of rubber
tissue or similar substance, rolled into a cigarette or

170 EARLY TREATMENT OF WAR WOUNDS

folded concertina-wise. If, however, the pus be par-
ticularly thick or profuse, it may be necessary to
insert, in addition, a tube for a short distance and
for a short time*

A drainage tube thrust amongst the fragments of
a shattered bone will tend to carry infection and to
cause necrosis of the fragments in contact with it.
A drain on each side, down to but not into the shat-
tered mass, will do all that is required.

Rigid drains in contact with pulsating vessels pre-
dispose to secondary haemorrhage. In a septic wound
they are practically as efficient in causing this as are
displaced fragments of bone or pieces of missile.

It is not good practice to draw a non- collapsible
drain through the whole length of a wound. It is
especially dangerous to insert tubes between the bones
of the forearm or leg. The tube is likely to cause,
by its pressure, sloughing of the interosseous mem-
brane, secondary haemorrhage from the vessels which
lie close to the membrane, and paralysis from destruc-
tion of the nerves which accompany those vessels.
In some cases, as has been pointed out, a u draw-
through ” gauze wick, impregnated with antiseptic
paraffin, is sufficient to prevent development of acute
infection.

Removal of Drains, — When one is certain that the
wounds are healthy, that is, if there be no necrotic
tissue or other infective material in the depth, it is
desirable to remove tube drains altogether, but it is
probably safer practice to shorten them gradually,
e.g. about one inch at a time. Rigid drains should give
place to soft drains (jaconet, battiste, torn glove, or

OPERATIVE TREATMENT

absorbent bandage) as soon as the discharge ceases
comparatively to be profuse* These serve to keep
the superficial part of the wound open, and do not
cause sufficient irritation to keep up the discharge,
as rigid drains may do.

Tension,— Tension in a wounded part militates
against successful treatment* It interferes with the
efficient circulation essential for the combatting of
infection. Tension must be relieved, whether in a
joint, in the thigh, in the chest, or in the brain.
Aspiration of a joint or pleural cavity may suffice*
(Sec chapters on these special injuries,)

General After-treatment, — The great indication
during the early stages of this period is to provide
as much rest and nourishment as possible* The
severely wounded man has previously come through
such a period of mental and physical stress that his
nervous system is more or less exhausted, and this
exhaustion reflects itself in impairment of the func-
tions of all important organs and of his power of
repair. It is, therefore, necessary to treat him with
the utmost consideration in every possible way* This
remark applies in a comparative degree also to the
man who has received minor injuries. Every wound
should be treated with respect, and careful watch
must be kept even on the most trivial, because cveiy
now and then, with sometimes very little warning,
complications such as tetanus, gas gangrene, or acute
streptococcal septicaemia may set in and cause rapid
death.

Rest must be procured by sedatives if necessary.
Usually some preparation of opium is used* The

172 EARLY TREATMENT OF WAR WOUNDS

preparation should vary with the particular case.
While morphia is the drug hitherto generally chosen,
it is not so good as omnopon or heroin for chest cases,
or omnopon for abdominal cases. In abdominal cases
morphia has a much greater inhibitory effect on the
bowel than omnopon.

The severely wounded man must be given nourish-
ment which he can digest.

Patients who arc in danger of developing gas in-
fection should be “ flooded ” with alkalis, by the
mouth, by the rectum, and, possibly, intravenously.
While the danger lasts, proteid foods should be given
sparingly. Easily assimilable carbohydrates should
form the staple diet, including candy sugar by the
mouth, glucose intravenously or per rectum, and so
on. The writer has found peptonized cocoa and milk
of considerable value in many cases.

The patient must be kept cheerful, encouraged in
every way. The presence of moribund eases has a
depressing effect, and an excuse can usually be found
for removing them to another part of the hospital
or at least to one end of the ward.

For patients who have suffered from severe shock,
it is a good working rule not to evacuate them to
hospitals farther down the line until at least twenty-
four hours after their blood pressure has become ap-
proximately normal and the pulse rate has descended
below a hundred, except when a distinct, and not
dangerous, explanation for the continued acceleration
exists. Cases of this nature, when evacuated too
early during periods of severe fighting, have died on
the train or shortly after arrival at the Rase, from a

OPERATIVE TREATMENT 173

recrudescence of surgical shock, or from a fulminating
septicaemia stirred up by transport in a patient whose
resistance is feeble.

In other respects each case must be treated on its

merits. No wound should be dressed unless some
special indication is present, and every wound should
be closed as soon as its condition will permit. The
general principles indicated already and in later
chapters on regional wounds should be followed
throughout convalescence as well as at operation.
Some patients have to be retained in casualty clearing
stations for considerable periods. Massage of the
surrounding parts and movement of the neighbour**
mg joints should be begun as soon as such pro-
cedures do not produce local or general reaction.
Active movements should be encouraged in gradually
increasing degree.

REFERENCES

The Early Treatment of Projectile Wounds by Excision of the
Damaged Tissue.” Captain E. T, C, Milligan. British Medical
Journal, June 26th, 1015, p. 1081,

“ The Treatment of Gunshot Wounds of the Head, with Special
Reference to apparently Minor Injuries,” ^lajor J. E, H«
Roberts, British MedicaL Journal, October 2nd, 1915, p, 499.

CHAPTER VII

WOUNDS OF THE BRAIN AND ITS COVERINGS

If wounds of the brain are left untreated until in-
flammation has obtained a hold, results to life and
function are, on the whole, more disastrous than in
comparable wounds of other parts of the body. Be-
cause of the importance and delicacy of the structure,
abnormalities, whether in the form of microbic in-
fection, displaced fragments of bone, foreign bodies,
blood -clot or pulped tissue, are apt to have far more
serious, and sometimes more rapid, lethal effects than
in other structures. Further experience has not in-
clined me to deviate in the least from the principles
which I enumerated in a paper published in the
British Medical Journal of February 19 th, 1916 . The
following chapter embodies that paper with very
slight alteration and addition.

The principles then enunciated were :

That infected gunshot wounds of the skull and
brain require more careful consideration and prompt
attention than similar wounds of any other part ;

That we can combat and prevent sepsis best by
early and complete operations ;

That we can prevent further permanent disability
in most cases by systematically removing foreign

THE BRAIN AND ITS COVERINGS 175

material or displaced bone from the surface or sub-
stance of the brain whenever these arc accessible to
legitimate surgery ;

And further, that, by these precautions, the imme-
diate results in the saving of life and more rapid
restoration of function, when that is possible, arc
better than those obtained by more conservative
procedures.

From time to time during this war there has been
manifest a tendency to imagine that modern brains
are more submissive to insult than those of our
forefathers apparently were. Even yet it is too early
to decide this point. Ail previous experience has
shown that the brain, sooner or later, resents the
presence of any abnormality in its immediate cover-
ings or in its substance. It is true that some small
lesions of the skull or small foreign bodies in the
brain have caused apparently no trouble to the
patient, even after years have passed ; but others,
seemingly equally insignificant, have caused intoler-
able inconvenience, due to late effects on the brain,
which removal of the exciting cause has not succeeded
in relieving. This is more true, of course, in cases
of* actual lesion of the brain than in injury to its
coverings. There was a considerable number of men
injured in the head during the South African War
who afterwards became a burden to the State owing
to derangements of the brain, and it must be remem-
bered that the maiming effects of sepsis in that cam-
paign were not apparent to anything like the same
extent as in this one. At the same time, it must be
said that there is evidence to show that much ol

r ^J

176 EARLY TREATMENT OF WAR WOUNDS

the subsequent disability may be functional in nature
and will clear up under suitable treatment.

It has hitherto always been the aim of military
surgeons to remove or ameliorate the physical defects
produced by missiles* Removal of displaced bone,
of foreign bodies, of blood-clot, or of any substance
which might interfere with rapid and smooth healing
of the brain has been considered of the utmost im-
portance no less than the combatting of sepsis* We
have discovered in this campaign no valid reason to
depart from this line of thought* The immediate
effect of sepsis, both in increasing the severity of the
focal lesion and in causing diffuse inflammation of
the brain and its coverings, have been impressed on
our minds with dreadful force. The power of the
brain to accommodate itself to extraordinary con-
ditions, or, one might say, the power of one part of
the brain to disregard even excessive injury of another
part, so that what is left “ carries on ” in a marvellous
way, has also been very striking* But who can fore-
tell that, later on, such eases arc to be free, as never
before, of sequelae which experience has shown to be
so frequently inevitable ?

Because of that experience, and because no one can
foresee how soon trouble will arise, it is surely right
that we should do all in our power to prevent probable
trouble. It is a matter of the greatest importance
to establish the best method of preventing or eradi-
cating sepsis, which is such a hindrance both to rapid
healing and to successful attack on physical defects
in the skull or in the brain. One is not justified in
formulating rules which arc based on results of opera-

THE BRAIN AND ITS COVERINGS 177

tioris performed at a period in the war when methods
of dealing successfully and rapidly with infected
wounds were not generally properly appreciated. It
has been found that septic wounds of the scalp and
skull arc particularly easy to deal with when compared
with others, in that they can usually be completely
excised* and the scalp sutured without danger. One
might almost say that this procedure* in the hands
of those who have mastered the necessary technique,
has robbed operation of its danger and has enabled
surgeons to obtain results which compare favourably
with those of equal magnitude in civil practice under
ordinary aseptic conditions. These remarks do not
apply* of course, to cases in which sepsis has already
obtained a firm hold in the lacerated brain. The
problems connected with such cases are much more
difficult. Apparently success is then dependent
chiefly on the provision of suitable drainage— a very
easy thing to say !

Fragments of bone, when driven into the brain,
are not usually septic at first, but tend to become
infected fairly rapidly. Jagged pieces of shell almost
invariably carry infection along with them. If large
pieces lodge in the brain, results arc very bad. Very
small pieces, on the other hand, may not cause any
trouble, but even they have been found sometimes,
later on, to become surrounded by large abscesses.
A rifle-bullet does not often carry in sepsis which the
tissues cannot overcome, but, after lodgment, in
virtue of its weight, it travels through healthy brain
tissue in the direction of the most dependant part.
The brain becomes diffluent under the press ute. One
12

178 EARLY TREATMENT OF WAR WOUNDS

has repeatedly seen such bullets alter their position
within a week to the extent of an inch or more* Here
there seems to be an indication for treatment by
posture — to make the wound of entrance the most
dependant part. At operation rifle-bullets have been
shaken out along the wound track , a procedure
recommended by Bier. It is likely that they would
find their own way more readily along a pulped track
than through healthy brain. If inaccessible at first
they may soon become accessible and be removed
by a secondary operation.

The following remarks have, of course, no reference
to very severe wounds caused by large pieces of shell,
in which such an extensive part of the skull and
brain is blown away or where a rifle-bullet causes
such explosive intracranial effects that the patient
does not survive more than a few hours.

We have seen many patients who, on admission,
have been suffering from complete hemiplegia, and
whose symptoms have cleared up in such a marvellous
and rapid way after operation that only a negligible
amount of paresis has persisted. On the other hand,
we have seen cases showing few or no symptoms, who
later developed serious complications and died
rapidly, in spite of operation. It appears, therefore,
that one ought not to pay too much attention to
focal symptomatology as a guide to treatment, or
even, in many cases, to prognosis.

We have seen many eases of extensive superficial
injuries with little or no damage to the brain, and,
on the other hand, many cases in which an insigni-
ficant-looking wound of the scalp and skull was

THE BRAIN AND ITS COVERINGS

associated with most extensive injury to the brain.
Whilst large, lacerated wounds are usually most
septic and suppuration in the brain apt to become
severe, yet we have seen cases of trivial and com-
paratively clean-cut wounds of the scalp associated
with extensive fracture, and, after a few days, with
such acute suppuration in the brain that only im-
mediate operation saved the patient’s life. The size
or condition of the wound, therefore, is no indication
of how the case will behave.

It has been said that oedema of the brain and
shock or concussion accompanying a serious injury
are such that operation at an early stage is dangerous.
Yet we know of many patients who are brought into
clearing stations in practically a moribund condition
who, after immediate operation, in a few hours have
so far recovered that they are able to speak intelli-
gently and take food. Their injuries heal up
perfectly well afterwards. It would thus appear
that so-called oedema and concussion are no bar to
success. Indeed, it is likely that both will pass off
more quickly when physical defects are remedied —
all the sooner the more thoroughly this is done. In
w r ounds of other parts, oedema and tension due to
interference with the circulation are relieved very
rapidly by incision, removal of foreign or lacerated
material, and drainage. How much more must relief
of the circulation be called for in a closed box like
the skull ! In such cases delay does not, therefore,
seem advisable. The use of the life-saving steel
helmets has undoubtedly introduced a difficulty in
some cases, which is absent in those who have not

o

180 EARLY TREATMENT OF WAR WOUNDS

been wearing a “ tin hat ” at the time of wounding.
Usually when a wound is caused by a missile which
has sufficient momentum to penetrate the helmet, a
variable amount of general brain concussion is pro- '
duccd. This must be allowed for in formulating an
opinion. The general concussion is, roughly speaking,
greater and more lasting than that caused by a small
focal force which has to overcome the resistance of
the skull alone. A wound caused by a missile which
has penetrated a steel helmet is more deadly than
one of apparently equal severity which occurs in a
patient who had not been wearing a helmet.

In passing, one may be permitted to draw attention
to the value of local anaesthesia for most of the eases,
and especially for the type just referred to. The
solution need be injected only into the scalp tissues
and pericranium. The skull, dura, and brain will
thereafter be found to be insensitive. If adrenalin is
mixed with the solution, bleeding from the scalp is
reduced to a minimum. If the patient is conscious,
it is advantageous to “dope” him with morphia,
or preferably omnopon, until he is decidedly sleepy.
In some cases nitrous oxide or a few whiffs of chloro-
form or ether can be given if much complaint is made
of the pain of the in jection* Local anaesthesia is now
widely used in head cases, with gratifying success*
Anaesthetists should acquire the necessary technique
in order to prevent loss of time.

After consideration of all these facts we are driven,
in deciding upon a course of action, to pay more
attention to the probable mechanical effects of the
injury, and the potentialities for infection rather than

THE BRAIN AND ITS COVERINGS 181

to worry much over the presence or absence of definite
symptoms. The lesion is a traumatic one, the
possibility of sepsis is great, and things should not
be left to chance or until the development of some
particular symptom. One must risk misinterpreta-
tion when one says such things. One does not wish
in the slightest to depreciate the value of clinical
investigation. Timely and effective operation does
not interfere with that. There is no doubt that the
lesions to be dealt with are chiefly mechanical
and microbic, and must be treated by mechanical
and anti-microbic remedies. If the mechanical dis-
abilities are not relieved, the complicating infection
has potentialities greater and more serious than in
wounds of other parts.

Treatment of Cases sent to the Base without
Operations, —While it is evident that the thorough
removal of physical defects is desirable at as early
a date as possible, there are objections to this, of
which the most important is that patients do not
travel well until at least a week or ten days after
operation. During a period of active fighting it may
not be possible to treat them all at the front. Only
the least serious should be sent to the Base at once,
so that they may arrive, before sepsis has got a firm
hold. At the front nothing should be done in such
a case further than to remove any visible foreign
material, to clean the wound of the scalp, and keep
it open by gauze or rubber tissue, after possibly using
some of the recently recommended antiseptic pastes
to antiseptieizc the surrounding skin, and to apply
a suitable dressing. This dressing should not exert

m

182 EARLY TREATMENT OF WAR WOUNDS

direct pressure on the wound, which will prevent
escape of discharge- A small roll of folded gauze on
each side will obviate this* Mere excision of the
scalp wound in an attempt to prevent septic develop-
ments only makes the task of the operator at the
Rase a more difficult one, and apparently entails
greater risk to the patient* Incomplete operations
give bad results* If operation is undertaken, the
accessible parts of the wound should be treated
thoroughly or not at all — all or nothing ! It must
be remembered that average cases arrive at the
clearing stations really in a less septic condition—
although the wounds may be superficially badly
soiled- — than they do at the Rase, and results in
similar cases should on that account be more favour-
able* Every effort should be made to operate during
the pre-in fia m mat ory st age *

Minor Operations- -Excision and suture of scalp
wounds are said by some to be unnecessary. Such
a judgment depends on the point of view. These
excisions, while they do no harm when proper tech-
nique is employed, make the patient fit for duty
again in a much shorter time ; they clear up diagnosis
with regard to fracture in most cases with absolute
certainty ; there is no doubt that thereby they
occasionally save life, and they certainly prevent
troublesome sequelae ; they save time and trouble
on the part of the attendants, and they save expense
in dressings* (The original mastisol and gauze
dressing may be left until the wound is healed (%
Major J* E* H* Roberts, recording 412 eases of
excision of scalp wounds, states that only in twelve

TIIE BRAIN AND ITS COVERINGS 183

did failure to obtain healing by first intention occur.
Three wounds gave way completely. In the others,
slight gaping, sloughing, or stitch suppuration oc-
curred. In one case a gap, G inches by 8, was success-
fully closed by sliding flaps.

Reasons for opening apparently Unwounded Dura.
— It has been shown repeatedly during this war
that a pronounced depressed fracture of the inner
table, although the dura may not be lacerated; is
accompanied by a localized, usually more or less
cone-shaped, bruising or pulping of the underlying
brain. The base of the cone corresponds roughly to
the area of comminution of the inner table. Owing
to its elasticity the inner table must always be de-
pressed considerably before it fractures, and the
sudden localized blow on the brain causes the pulping.
It must be remembered that the fragments of the
inner table may show little displacement at the
operation. The depth and severity of the pulping
varys with the depth to which the inner table has been
depressed. The amount of depression necessary to
cause fracture varies in different parts of the skull.
Such injury to the inner table and brain may exist
without a trace of injury to the external table. In
very rare eases intra-cerebral haemorrhage, sufficient
to cause severe pressure symptoms, may occur.

The pulped area — a mixture of useless brain matter
and blood— is an immediate source of irritation to
the surrounding brain, because it is virtually a foreign
body. In the process of healing a great part of it
is replaced by “ fibrous ” tissue— a scar— which
forms a remote source of irritation. The pulped mass

/

184 EARLY TREATMENT OF WAR WOUNDS

is liable to become infected, and to form a localized
abscess or to lead to spreading encephalitis or menin-
gitis, especially if the wound superficial to it is not
rendered aseptic at an early date.

In cases where the force has been so great that the
dura has also been ruptured, although pieces of bone
have not penetrated, a definite pulped track, extend-
ing even for a couple of inches, into the brain, may
be found. This, when, explored by the finger, re-
sembles closely the track made in the brain by a
foreign body. This shows the necessity for using
X-rays before operation, to reveal whether or not a
metallic foreign body is present. Operation should
not, however, be unduly delayed in order to have
this done. If the foreign body is beyond the reach
of the finger, it is usually beyond the reach of legiti-
mate surgery so far as the primary operation is
concerned. By fitting together the fragments of the
inner table one can often ascertain, with fair accuracy,
whether any fragments of bone have been forced into
the brain.

The mass of disintegrated brain matter and blood,
whether on the surface or in the depth of the brain,
interferes with the local circulation, and by this alone
causes irritation similar to a solid foreign body. After
its removal from either situation, pulsation usually
returns at once. (See later, 7.)

Such lesions may be accompanied by persistent
headache, focal spasm (often evanescent) or paralysis,
or even u optic neuritis.” Their presence can usually
be recognized, after the dura has been sufficiently
exposed, in that the dura is somewhat discoloured,

THE BRAIN AND ITS COVERINGS 185

the brain does not pulsate freely, and the area feels
doughy instead of elastic or springy.

The dura is usually opened by a small crucial
incision (fin,— fin.)* The angles of the flaps can
be drawn together again accurately by a single suture
(passed through them), if it is thought desirable and
safe. The pia-arachnoid may also be unruptured. In
such cases it is necessary to help out the pulped
material by inserting a small forceps and carefully
opening the blades. It usually wells out, however,
like grease from a collapsible tube. By getting the
patient to cough gently, lumpy pieces of clot or
detached brain are forced out. The “ cavity ,s may
also be cleared by suction through a soft catheter,
as Major Harvey Cushing has advised.

Pulsation returns very quickly. If healthy brain
matter is forced out, this indicates excessive intra-
cranial pressure, and lumbar puncture should be
done at once, A small drain, down to the hole in
the dura, may be left in the wound for twenty-four
hours.

Symptoms arc usually relieved within a very short
time. This relief is often most striking when the
dura is opened at a second operation, the first (re-
moval of depressed bone) having failed to relieve
the symptoms.

To my knowledge the dura has been opened de-
liberately in many scores of cases, with only one
fatality. The effect has been immediately and
uniformly beneficial. In four cases, at Base hospitals,
in which the operators thought that the procedure
was inadvisable, death occurred from abscess of the

/

186 EARLY TREATMENT OF WAR WOUNDS

brain, spreading encephalitis, or meningitis* It is
essential for safety that, before opening the dura, an
aseptic field of operation is obtained. Neglect of this
precaution was, in my opinion, the cause of death in
the fatal case referred to.

Operations where Wounds ol the Blood Sinuses are
present.— These should be done as a matter of course,
because it is advisable to remove depressed fragments
of bone or foreign bodies :

(a) which cause obstruction to the return of blood
from any part of the brain, and

( b ) which may be, or may become, infected, and
cause septic thrombosis*

It seems all the more desirable to remove such
fragments, if they actually penetrate the wounded
sinus, The operation is, per se, not a dangerous one
if proper technique is employed. For example,
fourteen cases in one series after a battle were operated
on. Only one died, and he had severe laceration of
both cerebral hemispheres, besides the wound in the
longitudinal sinus.

Drainage of the Brain* -It is difficult to formulate
any hard-and-fast rules for drainage of the brain.
On the whole, it is probably best not to drain unless
one is forced to do so. The presence in the brain of
actual pus, of infected blood-clot, of inaccessible,
definitely infected foreign bodies, or of profuse oozing
from a seriously lacerated area, are the chief in-
dications for it. It is usually unnecessary to drain,
even some days after receipt of the wound, if it is
found that pus is absent from a track which foreign
bodies have made. In some cases one may feel,

THE BRAIN AND ITS COVERINGS 187

however, that it is safer to insert a short drain
for twenty-four hours or so. When aseptic foreign
bodies, such as bone fragments, have been extracted,
or when an area or track of pulped brain matter
has been evacuated in which no penetration of
foreign bodies has occurred, it is unnecessary to
drain the cavity in the brain, but folded rubber
dam should always be inserted, from the angle of the
wound, “ down to, but not into,” the opening in the
dura, for twenty-four hours- If pus, “ smelly ”
blood-clot, clothing, hair, or a jagged large piece of
metal is evacuated from considerable depth, a drain
should be inserted into the track, and it should be
brought straight out through an unsutured part of
the excised wound. Bacteriological examination ol
what is removed should always be made, even though
actual pus is absent- If streptococci are found
drainage should be maintained until the organisms
disappear or become very few in number. If strepto-
cocci arc absent it is fairly safe to be guided by
clinical signs alone, as to time for removal of drains.
It should be remembered that foreign bodies,
especially flat pieces of bone, compress the brain in
front of them ; therefore, although they may be
found at a depth of, say, l|in. to 2 in., it is not
necessary to push a drain to that depth. The distal
end of the track will, after extraction of the foreign
body, be found to have approached considerably
nearer the surface of the brain. If one attempts, in
such a case, to push a stiff drain in for a couple oi
inches, there is great likelihood that the lateral
ventricle will be perforated by it. One should,

m

I

188 EARLY TREATMENT OF WAR WOUNDS

immediately before inserting the drain, gently explore
the track with the finger, and push the drain in only
so far that it will not quite reach the extremity of the
track.

As a rule, the drain should be shortened slightly
every day or every second day, unless pus continues
to discharge from the depth in fair quantity. It
should be borne in mind that a drain, especially a
rigid one, acts like any other foreign body, and may
stimulate pus formation, besides providing a channel
for possible entrance of fresh infection* All drains
should, on this account, be removed as early as
possible. In most cases they can be taken out after
twenty-four to forty-eight hours.

Rigid drains arc harmful to the brain, especially
those with holes cut in them. The intracranial
pressure may force normal brain through the holes
or end of the tube. The constant friction of the
pulsating brain against a hard foreign body must
have a bad effect. The most satisfactory drain, on
the whole, seems to be a piece of rubber dam, jaconet,
batiste, or similar substance, folded concertina-wise.
No apparent harm has followed the insertion, on the
point of the finger, of a small amount of a paraffin
paste (B.I.P.P., flavine, brilliant green, dichloramine-
T, etc.). In certain cases, where the pus is particu-
larly thick or profuse, or where streptococcal infection
is present, it may be advisable to insert, in addition,
one or two narrow tubes. A few drops of a thin
antiseptic paste may be instilled gently, after the
tubes have been inserted and again before they arc
removed.

THE BRAIN AND ITS COVERINGS 189

Ono must be careful, when inserting a drain, that
no damage is done to the healthy brain lining the
track. One must, therefore, note the direction of the
track very carefully.

So long as a drain is in use, the surrounding scalp
should be smeared with an antiseptic paste, or painted
repeatedly with picric acid solution.

Points constantly to be kept in Mind. — (1) There
may be multiple injuries, therefore always have "the
whole scalp shaved.

(2) The force causing the injury is usually very
circumscribed, and its effects arc, therefore, likely to
be localized to the immediate neighbourhood of the
part which has been struck. Injury by contre-coup
has not often to be considered, although examples
of this arc more frequent since the introduction of
the steel helmet.

(3) Such localized forces, if they have been great
enough to cause depressed fracture of the inner table,
result, practically always, in definite injury tothc brain,
which asserts itself by immediate or remote cerebral
disability. This may occur in pronounced form,
although the dura is uninjured ; in rare cases it has
occurred even when no fracture of the external table
has been seen. One need not refer to cases of im-
mediate disability. Some interesting examples of
remote disability have turned up even in France.
We have seen a good many cases now of men who
were wounded early in the war, and whose wounds
were considered so insignificant at the time that the
patients were not even sent down the line. Later,
they were invalided on account of symptoms eaused

190 EARLY TREATMENT OF WAR WOUNDS

by the physical defect of the skull— to wit, depressed
fracture of the inner table — which, of course, was
treated without more delay,

(4) Experience has shown that a properly con-
ducted, complete operation, while it cannot undo the
already existing damage to the skull or brain, facili-
tates repair, gives better immediate results, and tends
to prevent troublesome sequelae more surely than an
incomplete one,

(5) Practically in all cases which survive longer
than a couple of days, death is due to the effect of
sepsis on the damaged brain. In any case, sepsis will
increase the amount of damage to the brain. The
local injury, when thus complicated, is likely to

interfere with intellect or set up permanent paraly-
sis,” Apart from that, sepsis may cause necrosis of
bone, and thus prolong convalescence. The necessity
for early operation is evident,

(6) As our efforts will, therefore, be nullified in
large measure unless sepsis is overcome, all operations
must be preceded by removal of the sepsis from the
area to be dealt with. Excision or cauterization of
the infected parts is the most rapid and certain way
of doing this. It is only in very rare cases that this
is not feasible. If it is not, the patient has probably
very little chance of pulling through. The wound of
the scalp and pericranium must be removed en masse ,
The fractured area must be dealt with in the same
way, although, if a hole in the bone already exists, its
margins can be nibbled away with equal success.
Proper technique is essential. It must be pointed
out that to excise the wound after turning down the

THE BRAIN AND ITS COVERINGS 191

flap is merely courting disaster. Tlic brain cannot
be dealt with so vigorously, but removal of pulped,
useless material, and of foreign bodies, will allow it
to combat any infection more successfully. “ Healthy
brain substance possesses considerable power of
limiting microbic invasion,” but one cannot say that
pulped brain, or brain with foreign bodies embedded
in it, is healthy ! As already indicated, in the majority
of cases in which bone fragments alone are forced
into the brain, the track leading down to them is not
infected at first, but it rapidly becomes so,

(7) Foreign bodies in the brain act deleter iously
in four ways : (a) By their direct effect on the delicate
pulsating brain tissue, (b) By favouring the develop-
ment of sepsis. It is practically an everyday oc-
currence, when cases arrive late during a u rush,”
to And suppuration around pieces of bone lying at
the end of a track in the brain, (c) By interfering,
in rather an obscure way, with the circulation of the
brain. A mass of pulped brain matter acts in the
same way. It is very common to find that the brain,
when exposed at operation, does not pulsate, or does
so only to a slight extent, until the fragments of bone
or disintegrated matter are removed from the depth,
when it begins to pulsate freely. A normal circulation
is essential to satisfactory recovery, (d) By causing,
when they become encapsuled, a localized, connective
tissue mass, which may act as deleter iously as a
tumour. If recovery of function is possible, early
removal of foreign bodies will procure this more
certainly, more rapidly, and probably more com-
pletely than is otherwise feasible— a great improve-

192 EARLY TREATMENT OF WAR WOUNDS

ment is frequently noted within twenty- four hours.
If carefully done, further damage to the brain is not
appreciable. Only once have I seen any immediate
increase of paralysis follow, in a case where an un- *
usually large piece of bone had to be removed from
a suppurating track. One will probably do less harm
to the brain in removing a foreign body through an
already existing track than by cutting a way through
a mass of fibrous tissue, or, worse still, healthy brain,
as has to be done when the operation is postponed
until the scalp has again become intact.

(8) It is highly desirable to try to prevent the
formation of cicatricial tissue, whether on or in the
brain, even though in the latter case it may resemble
neuroglia. Such scar tissue acts as an irritant chiefly
by preventing normal movement of the brain, by
interfering with the circulation, and, in many cases,
by causing pain. The nature of the injury, the
amount of sepsis, the presence or absence of foreign
bodies, and the treatment employed have much to
do with the amount formed. Operation and after-
treatment should be carried out in such a way that
the minimum quantity of cicatricial tissue results.
Unsuitable drains, especially when kept in for a long
time, stimulate its formation. The trephine opening
should be covered completely with healthy scalp. If
plastic flaps are used at the end of the operation to
cover the defect, it is found that the line of suture
usually lies over intact bone. If incisions are made
which merely radiate from the wound, the apices of
the resultant flaps meet over the hole in the dura.
Such incisions should be used only when it is obvious

THE BRAIN AND ITS COVERINGS 193

that free drainage will be necessary. Because frag-
ments of bone are likely to be infected, it is dangerous
to replace any of them. The scalp wound, after exci-
sion, can usually be accurately sutured — in some cases
it may be necessary to perform a plastic operation,
by sliding scalp Haps. This is greatly preferable to
merely covering the exposed brain by a flap of muscle,
pericranium, or aponeurosis. Such a flap, if exposed
at the bottom of a wound, is apt to necrose. In any
case, the amount of cicatricial tissue and of permanent
adhesion is greater in a wound which heals by granu-
lation than in one which heals by first intention. It
is true that Nature has a marvellous capacity for
remedying defects — even by making a new dura. The
greater the amount of abnormality, however, with
which she has to cope, the greater will be her difficulty
in imitating the status quo ante. Therefore, we should
help her in every possible way. When this help is
given efficiently, the wound responds by healing per
primam. Surgeons who have kept statistics will
support the statement that, in patients who recover,
at least 90 per cent, of the wounds behave in this
desirable way.

Objects of Treatment. — The objects of treatment
can now be shortly summed up.

(1) To prevent or remove infection, thereby pre-
venting further destruction of tissue.

(2) To establish diagnosis in some cases of doubt.

{3) To remove all sources of irritation to the brain,

if this can be done without causing further serious
damage to it. One cannot undo the initial surface
wound or cerebral lesion, but one can try to procure
13

a

194 EARLY TREATMENT OF WAR WOUNDS

a condition which will allow healing to occur more
rapidly, more normally, and with the least possible
permanent impairment of function*

(4) In any case to procure rapid healing of the
superficial parts, provided that the brain is safe*

The charge of being too zealous in operating on
head injuries may be made. I cannot remember
death occurring after any operation which was not
one of urgency. We have regretted that we have
not operated, or operated sooner, on some patients
who have done badly* In all injuries it is claimed
that operation furnishes an additional and usually
accurate means of diagnosing the extent of the lesion.
In minor injuries it has done no harm so far as can
be ascertained, and it renders the patient fit to return
to duty at a much earlier date than could otherwise
be the case.

It is better to send a patient home with a healed
scalp and healthy skull, inside which are the fewest
possible potentialities for future brain trouble, than
that he should go with the prospect of a later operation
on an area which is obscured by many abnormalities*
If it can be shown that this is done with as great
safety as attends more conservative methods, the
procedure is more than justified.

Sepsis and the exigencies of war will always make
the proportion of failures a relatively high one.
Unless military exigencies permit of “ head ” eases
being retained near the front for operation and for
a fairly long after-treatment, mortality and loss of
function are increased*

The Routine of Treatment.— On admission of the

THE BRAIN AND ITS COVERINGS 195

patient the hair should be shaved off or removed
with a depilatory paste, the wound thoroughly
examined (the use of a probe is deprecated), two
skiagrams taken in planes at right angles to each
other, and neurological examination made* If all the
hair is not removed, other wounds, sometimes more
important than the most noticeable one, may be
overlooked* An aperient should be given, and the
administration of urotropine (15 to 20 grains every
three or four hours) begun* If the brain is injured,
it is well, if possible, to make a bacteriological exami-
nation of the discharge, for future guidance* If brain
matter is exposed or is exuding from the wound,
operation should be carried out as soon as possible.
In most other cases, in absence of urgent symptoms,
there need be no great haste, but in no case should
operation be postponed for longer than a couple of
clays. The superficial wound should meantime be
treated as already described {p. 181).

Wounds o£ the Scalp* —The majority of wounds of
the scalp should be excised, and the bone beneath
carefully examined. The wound itself should be
cauterized, or dessicated by thorough rubbing with 5
to 10 per cent, picric acid in spirit and drying with
a swab. After disinfection of the wound and sur-
rounding scalp the damaged soft tissues arc excised
by a lemon-shaped or elliptical incision, down to bone ,
about a quarter of an inch from the lacerated margins.
If the periosteum is carefully divided, especially at
the ends of the incision, it is easy to remove damaged
scalp and pericranium en bloc , with the handle of the
scalpel or with a periosteum elevator, if no further

196 EARLY TREATMENT OF WAR WOUNDS

interference is made, the wounds can be sutured,
usually without drainage. It may be necessary some-
times to slide flaps in order to make up for defects.
Sufficient access to the bone and brain can, in almost
every instance, be got through the incisions recom-
mended. Turning down a U-shaped flap introduces
a needless complication, and frequently prevents
suture of the excised original wound. If this wound
cannot be closed, healing by granulation must
take place directly over the wound in the dura
and brain — an obvious disadvantage. Covering the
exposed brain with pericranial or muscular flaps,
which arc left exposed in the depth of the wound, is
rather a precarious procedure. In practically all
cases, the area of operation can be covered in bv
healthy scalp, by simple suture, or by a plastic opera-
tion such as described later.

The use of the U-flap of civil surgery is advisable
(a) in removing a foreign body through an unwounded
area, and ( b ) in contra- lateral decompression opera-
tions for hernia cerebri.

Depressed Fracture. — Every case in which depicsscd
fracture of the skull is suspected should be explored
without undue delay, whether sepsis is present or
not. Delay, which used to be indulged in waiting
for surface wounds to clean— too frequently leads to
dangerous intracranial developments. 11 the edge oi
the wound is much inflamed and infiltrated, treatment
with hypertonic saline applications, or a paraffin paste,
usually makes it fit for excision in twenty-four to
forty-eight hours. In most cases it is possible so to
excise the wounds in both scalp and bone that an

THE BRAIN AND ITS COVERINGS 197

aseptic field of operation is left. If sepsis has already
penetrated to the depth of the brain, the sooner
operation is done the better.

The injury comes under one of the following
varieties :

(1) Cases without Definite External Signs of Depressed
Fracture. -“Because fracture with displacement of the
inner table or some other suberanial lesion may
be present, it is important that operation should be
carried out.

(a) When the entrance and exit wounds are sepa-
rated so far by a bridge of scalp that the line joining
them traverses the bone, or if the patient has been
stunned at the time of injury, the presumption is that
the bone lias been damaged. Such wounds, and the
track between them, as well as single gaping wounds
of the scalp, should be excised en masse, including
the pericranium. Injury, even mere bruising, of the
periosteum usually means that the internal tabic has
suffered. If focal loss of function (even although
evanescent), persistent headache or giddiness, or
other more definite signs of cerebral compression are
present, especially if optic neuritis coexists, tre-
phining should be done, e ven in the absence of definite
laceration of the periosteum.

( b ) If fracture of the outer table without depression
is found, or even if the bone is merely bruised, the
external table should be removed by a small trephine,
and the inner table examined. Depressed fracture
of the inner table may exist without any apparent
injury to the external table or any cerebral symptoms,
and only the very best skiagrams will show such a

198 EARLY TREATMENT OF WAR WOUNDS

fracture. If the internal table is fissured or depressed,
discoloured, or infiltrated with blood-clot, and if focal
or other symptoms described in (in) have been present,
the internal table should also be removed and the
dura examined.

(2) Fracture with Depression* but without Laceration
of the Dura Mater— The fractured and probably
septic bone is excised cither by making very small
trephine, or “ burr,” openings, outside the soiled area,
and completing the removal with a skull-cutting
forceps (e.g. Montenovesi or de Vilbis) just wide of
the shattered bone, or by the “ nibbling ” method,
using a properly devised small gouge forceps. It is
better to work with a small forceps and nibble the
bone away in small pieces, than to use a large, powerful
forceps, which may cause extensive fissure fracture.
After removal of the soiled edge of the wound in the
bone, a fresh forceps should be used to nibble away
a further portion. The former trephining method is
theoretically the better technique, but the latter
is simpler, gives equally good results, and does not
entail removal of so much bone. It is not necessary
to trim the edge of the resultant opening in the bone
accurately. It seems likely that bone grows out
more readily from an untrimmed margin, so that the
opening may become greatly reduced in size. If the
dura is apparently normal and the brain pulsates
well, the operation can then be completed by suture
of the scalp, with or without drainage. If, however,
the dura is muddy-looking ; if there is loss of pulsation
and circumscribed loss of elasticity, especially if focal
symptoms have been present after the wound was

THE BRAIN AND ITS COVERINGS 199

received, the dura should be opened. This is usually
best done by a small crucial incision* Disintegrated
brain and blood-clot arc squeezed out by the vis a
ter go , If the pulped material docs not come out quite
readily, it may be helped out fay inserting a small
artery forceps for a short distance, and opening the
blades so as to dilate the hole in the dura and under-
lying membranes, or fay getting the patient to cough
gently. Only the useless matter will exude unless
the intracranial pressure is high, in which case lumbar
puncture is indicated.

(3) Injury of Dura without Foreign Body or Evident
Sepsis. — Fracture with injury to dura mater, when
no foreign body is present and the wound in the
brain is at first probably aseptic, occurs frequently.
After excision, en masse as before, the scalp wound
may be enlarged in any desired direction in order
to procure adequate access. The bone around the
fracture is cleared, A “ trephine n opening is really
rarely required. The spicules arc removed, and the
skull cut away carefully with forceps to an extent
varying with the injury to the dura. A clear margin
(one-third of an inch) of uninjured dura should be
exposed* Great care must be exercised to separate
the dura from the bone while this is being done.
Ragged edges of dura should be excised. If a

track !J exists in the brain, this should be carefully
explored, by the finger if possible, and any collection
of pulped brain tissue allowed to escape* If the
opening in the dura admits the index finger, there
need be no fear of injuring the brain to a greater
extent if the procedure be carried out with sufficient

200 EARLY TREATMENT OF WAR WOUNDS

care. Otherwise, the debris should be sucked out
by catheter. If thought advisable, a piece of apo-
neurosis may be placed across the opening in the dura
and the operation completed by suturing the scalp
wound. A drain should reach from the opening in
the dura through one end of the wound. It should
be removed after twenty-four hours. If sepsis asserts
itself, the wound should be opened up freely at once.

(4) Injury to the Dura complicated by a Foreign
Body in the Brain and by Sepsis. — The position of the
foreign body is previously localized by X-rays. At
the operation (as in 3), the track through the brain
matter can usually be explored by the index finger.
It may be necessary to enlarge the wound in the dura
slightly. The foreign body having been located, a
suitable, slightly curved, scoop is passed along the
linger, and under the foreign body, which is then
pressed against the point of the finger, and all three
are carefully and gently withdrawn. The greatest
delicacy of touch is required during this procedure.
The linger, in a flexible manner, must follow the
previously formed track, and must not break through
uninjured brain substance. Any stiffness of the
finger must be avoided. The use of a forceps is apt
to increase the damage to the brain. A foreign body
or piece of bone may often be coaxed out by making
very slight flexion movements with the distal phalanx
of the examining finger. If the track will not admit
the finger, the foreign body can, as Cushing has
suggested, frequently be extracted by allowing a
round-bodied 4-in. steel nail, with smooth, blunted
“ point,” or a similar specially made searcher, to slip

THE BRAIN AND ITS COVERINGS 201

along the track, actuated by gravity alone, and then
connecting it with wires from a magnet of sufficient
strength. If the foreign body is magnetic it adheres
to the nail and is carefully removed (p. 205).

A catheter is now passed along the track, and
suction made until every particle of debris and clot
is removed. This should be done with special care if
the lateral ventricle has been opened.

A drain should be inserted in all eases, as already
described (3). If definite sepsis is present drains
should be inserted in the superficial part of the track
leading straight out through the wound. In the
worst cases the scalp wound should not be sutured
till all danger has passed.

The exploration for foreign bodies by the finger at
the primary operation, when the existing opening in
the dura is large enough to admit it, is justified by the
following considerations : (1) A track through brain
substance is already present ; (2) only very rarely is
further injury to the brain caused by the procedure ;
(3) the frequency with which an abscess develops,
should the foreign body be left in the brain ; (4) if
the wounds are large, sepsis has almost certainly
penetrated along with, or following, the foreign bodies,
and, as has been said, the sooner they arc dealt with
the better.

As already indicated, foreign bodies imbedded in
the brain, by their direct influence and by their
interference with the cerebral circulation, may produce
symptoms of focal irritation and of compression, or
increased intracranial tension. If their removal does
not immediately relieve these, and especially if hernia

*

202 EARLY TREATMENT OF WAR WOUNDS

cerebri is threatened* lumbar puncture should be
resorted to, and repeated several times il necessary*
If this fails to relieve the intracranial tension, contra-
lateral subtemporal decompression may give relief,
but has, on the whole, proved an unsatisfactory
operation under these septic conditions.

Major Harvey Cushing, in his excellent paper on
penetrating wounds of the brain, published in the
British Medical Journal, Feb. 23, 1918, makes the
following remarks with regard to treatment of the
track and of retained missiles*

“ Much more serious is the retention of the dis-
organized and devitalized cone or cylinder ol cere-
bral tissue which lines the track, and in which the
indriven bone fragments are embedded* Though
extraction of these fragments is advocated, no special
emphasis has been laid on the desirability of thorough
removal of the pulped tissue which surrounds the
pathway of the missiles, and which, like devitalized
tissue of any kind, is a soil favourable to the growth
of organisms.

“ As Colonel Gray has suggested, if the patient is
encouraged to cough, clots and cerebral debris often-
times may thus be expressed, and some have em-
ployed gentle curettage or irrigation ; but, if a finger
is introduced in the track for purposes of exploration,
the disorganizsd and soiled cerebral tissue lining its
walls will be crowded inward, whereas every effort
should be made to get it out,

“ Almost from the outset reliance was placed on
the use of a flexible, soft-rubber catheter as a means
of determining the exact direction taken by the

)

1

THE BRAIN AND ITS COVERINGS 203

missiles, whether a metallic body, or bone fragments,
or both. Without the production of additional
trauma one may investigate in this way even the
narrowest track, and it will be found that the pre-
sence and situation of any indriven bone fragments
can be detected with almost as great delicacy as by
direct palpation.

“ By attaching to the end of the catheter a
Carrel-Gentile glass syringe with its rubber bulb it
is possible to suck up into its lumen the softened
brain, which can then he expelled from the catheter
as paste is expressed from the orifice of a tube. The
process should be repeated until the cavity is rendered
as free as possible of all the softened and infiltrated
brain. It will be found that the adjoining normal
cerebral tissue, unaffected by the original contusion,
will not be drawn into the tube by the degree of
suction which can be applied by the average rubber
bulb.

4 6 Not infrequently bits of bone come away in the
eye of the catheter, and on one or two occasions a
small foreign body has thus been withdrawn. Mean-
while, as the track becomes clean and the tension and
tendency of the brain to herniate subsides, it is
possible with delicate duck-billed forceps to pick out
from the track one by one the bone fragments, whose
depth and position can be determined by the un-
mistakable sensation they impart to the catheter,
which thus supplements the information given by
the oj-ray plates. The technique of the performance
will quickly be acquired by any one who may wish
to put it into practice.

I

204 EARLY TREATMENT OF WAR WOUNDS

“ In not a few cases in the series the missile and
bone fragments have been driven through into the
ventricle, and in the process of suction the cerebro-
spinal fluid spaces have been sucked completely dry.
These ventricular penetrations have been met with
in twenty- five eases, and it is by no means as desperate
a condition as is generally supposed* Many cases
with opened ventricle, when treated in this way, have
made perfect recoveries, as will be related in a more
detailed communication which will permit of case
reports,

“ Any procedure is capable of being abused, and
even a soft flexible catheter may possibly be forced
to do damage. Even those who advocate digital
exploration admit that damage may be done thereby
unless the greatest care is exercised ; but we must
recognize that the surgical profession contains its
Little Jack Horners, and it is better, on the whole,
for all of us to keep our fingers out of the brain so far
as possible.

44 Retained Missiles. -It goes without saying that
it would be the ideal treatment, at a primary operation
for a penetrating wound, if the foreign body could
always be removed. Otherwise the operation must
be regarded as incomplete, with a far greater likeli-
hood of subsequent abscess formation than if removal
of the missile has been accomplished. It is equally
true that foreign body extraction, no matter how
desirable as a means of avoiding these possible
secondary complications, should never be forced to
the point of increasing the damage to the nervous
tissues already done by the penetration. Some say

THE BRAIN AND ITS COVERINGS 205

4 avoid infection at any cost 5 ; others & better a
fatality from infection than the certainty of per-
petuating paralyses/ Between these two schools
one must decide in the individual case.

‘ 4 It is well known that many, even sizable bodies—
a shrapnel ball, for example — may be retained without
provoking symptoms; but, even so, the writer has
known of abscess formation around such a missile
first giving evidence of itself a year after the injury.
The middle ground position is the safest one-
name Iy s always to extract a foreign body if if can
be accomplished without increasing the damage
already done.

41 4 This discussion applies solely to deeply implanted
missiles, for all agree that superficial and easily
accessible ones should of course be removed. Ex-
traction with a magnet is the only justifiable method
applicable to deep-seated bodies, and can often be
accomplished after suction of the track in the usual
method by gently sliding into it, to the proper depth,
a French wire nail with rounded point. Contact with
the proximal end of the nail is then made with a
portable electro-magnet, which need not be a weight
greater than can be easily handled, and if the foreign
body is magnetizable and proper contact secured it
will be withdrawn along its own track of entry.

“ The extraction was successful in eleven cases in
the series in which the missiles would otherwise have
been inaccessible. It would have been preferable to
place the interposed nail in exact contact with the
foreign body under the direction of a fluoroscope, but
our situation did not permit of this. The procedure

/

206 EARLY TREATMENT OF WAR WOUNDS

is capable of great development, and next to the eye
the brain is the most favourable place for employing
the magnet*

“ All of the foreign bodies from which cultures
were made gave a growth of organisms— usually
streptococcus, staphylococcus, or some gas-producing
bacillus.”

(5) Fracture with Injury to one of the Blood Sinuses.

— Operation in such cases may be difficult on
account of the alarming haemorrhage which may
occur during exposure of the sinus. It should not,
therefore, be undertaken by an inexperienced opera-
tor. The size of the superficial wound of the scalp
or skull gives no indication of the extent of the injury
to the sinus. The results of such operations have
been very favourable. Three of the procedures
recommended for control of such haemorrhage have
practically been given up -namely, lateral application
of suture or forceps, plugging with gauze, and ligature.
Plugging and ligature especially must be avoided
behind the entrance of the parietal lacunae or ccrebial
veins. It has been found that practically all cases,
which survive the immediate effects of the injury,
are amenable to treatment by the application of a
piece of aponeurosis, cut from the edge of the scalp
wound or from the fascia lata of the thigh. The
procedure is known as the postage stamp
operation.

It is often advisable to remove the fractured area
of bone en masse , as described under (2), Care must
be taken not to dislodge any piece of bone which
may be plugging the sinus. In other cases the

THE BRAIN AND ITS COVERINGS 207

fragments can bo lifted out, and, if necessary, better
access obtained by rapidly clipping away adjacent
bone. During this procedure the bleeding may have
to be controlled by gauze plugs*

After free and rapid exposure of the hole in the
sinus, haemorrhage therefrom being controlled by
light gauze pressure, the stamp ” should be cut and
spread on the palmar surface of the point of the
operator’s gloved index finger, or on a small swab
covered with batiste or rubber tissue* The perfora-
tion is then blocked by a finger of the other hand*
All blood-clot is carefully wiped away, the controlling
finger is removed, and the ** stamp ** applied rapidly
over the perforation. Fairly firm, equable pressure
is kept up for a few minutes, when the graft will have
adhered to the wall of the sinus* If the tear is a
large one, the “ postage stamp ” and swab may be
bandaged in position for ten minutes or so. A hole,
measuring f in, by ^ in., has been closed successfully
in this way, and, judging by the ease with which this
was done, it should be possible to close even larger
ones. In rare cases it may be necessary to suture
one side of the graft to the dura before placing it over
the opening. It may thus more easily be held in
position. The graft should always be covered by
scalp at the end of the operation. In these cases it
is practically always possible to suture the scalp
wound completely. A small, soft drain is inserted
close to, but not on to, the graft, and is withdrawn
in a day or so.

lumbar Puncture* —Lumbar puncture has fre-
quently been found to give relief in eases of local

m

208 EARLY TREATMENT OF WAR WOUNDS

circulatory disturbance after operation— evidenced,
for example, by persistent headache, recurring focal
muscular spasms, or slight hernia cerebri. The
amount of ccrcbro-spinal fluid withdrawn varies with ^
the pressure of the fluid. It is rarely necessary to
remove more than 25 c.cm. or thereby. Usually,
the withdrawal of a much less quantity suffices.
The process may be repeated several times if thought
advisable. It ought to be resorted to before any
marked signs occur.

Certain cases of large fungus cerebri have been
cured by this procedure. If fungus is present, how-
ever, while it is to be regarded as a symptom of
increased intracranial tension, it must be remembered
that this last is frequently due to the presence of
foreign bodies or abscess in the brain, or to more
diffuse encephalitis or meningitis, and suitable re-
medies must be used for these conditions. If menin-
gitis is present, or if the fungus is fairly recent, rapid
removal of cerebro-spinal fluid may allow infection
to spread.

The wound should always be exposed for inspection
when lumbar puncture is done, as this may cause the
herniated brain to sink back to a considerable depth,
and protective adhesions may be torn. If lumbar
puncture fails to alleviate the condition, a contra-
lateral decompression operation may be tried.

Spirit dressing is usually employed for such cases.
Picric acid (l to 1 per cent.), or some astringent
preparation may, with benefit, be added when
discharge is free. The free application of B.I.P.P.
lias been found of great value in many eases. The

v_;

THE BRAIN AND ITS COVERINGS 209

dressings should be tucked into the gutter between
the base of the hernia and the bone.

In most cases of hernia cerebri it will be found that
posture has a marked effect, the protrusion being
lessened when the patient is propped up in the
“ Fowler position,” This position should be adopted
in all cases immediately after operation, A smart
intestinal purge is also sometimes effective. If a
very large amount of cerebro-spinal fluid has to be
withdrawn, the patient should be laid flat until the
intracranial and intraspinal pressure has had time
to become equalized.

It is not advisable to make lumbar puncture in
the early stages after a wound of the brain has been
caused, unless the dura is intact, or until the exact
local conditions have been revealed by operation.
Adhesions in the neighbourhood of the wound are
very slight at this period, and sepsis may easily be
dissipated.

Closure of the Scalp Wound* — In the great majority
of cases the elliptical wounds resulting from excision
can be closed, owing to the mobility of the scalp, if

all layer ” sutures are used with superficial sutures
between. It is well to work from each end in tying
the sutures.

In cases where complete closure cannot be obtained
by this method, one must not hesitate to make a
plastic operation, to which the scalp is particularly
adaptable.

A successful and widely used method is by ex^
tension of the original incision to form a large U or
S flap.

U

/

iss

M

THE BRAIN AND ITS COVERINGS 211

The ends of the wounds may be sutured to reduce
the amount of plastic necessary (fig, 20).

An u S J5 incision is made as indicated by the
dotted line {fig, 20). The end A should extend well
beyond a line drawn at right angles to the main axis
of, and through the end of, the raw area. The scalp
is undermined completely to any desired extent, as
indicated by the shaded area. This is easily done

Fig. 22.— Cranial Injuries, Diagram of plastic operation for
triangular defect.

bv thrusting a curved, blunt-pointed scissors, con-
cavity towards the skull, between the aponeourosis
and pericranium, opening the blades and with-
drawing, Here and there it may be necessary to
cut resistant strands of tissue. Suture at a- a' to see
how the flap comes up* Sutures at the base of the
flap should be inserted obliquely as at b-b\ c-e' ; when
tied they help to remove tension. When fully sutured.

212 EARLY TREATMENT OF WAR WOUNDS

there should be little tension — if there is much, the
scalp should he scarified repeatedly between the
sutures, sufficiently to draw blood.

The line of sutures, when tied, lies frequently
completely to one side of the wound in the dura.
This method thus has an advantage over that of
turning down a flap, and is no more elaborate. For
a triangular defect, proceed as shown in fig. 22.

General Remarks about Operation, — The operation
necessary in the majority of head injuries is a com-
paratively simple one. If preceded by infiltration of
the scalp w r ith local anaesthetic and adrenalin, hae-
morrhage and shock are obviated to a very great
extent, and the operation is made even more simple.
The dangerous haemorrhage which may occur from
large flap incisions is entirely prevented by infiltration
of the incision area with adrenalin solution, and, if
some local anaesthetic has been added, the amount
of general anaesthetic required is either nil or neg-
ligible.

The use of mastisol (p. 165) is recommended for
fixing the gauze dressings. Drains are drawn through
small slits in the gauze, and can be removed without
disturbing the wound, 1

All serious cases should be kept at the casualty
clearing station for two or three weeks after operation,
and even longer if one is not quite satisfied with their
condition.

* An excellent prapamtion of “Mastisol M vamieh may be obtained
from Burgoyne, Rurb ridge & Co., Coleman Street, London.

CHAPTER VIII

PENETRATING WOUNDS OF THE THORAX

In the early stages of the war it was generally thought
that men wounded in the chest, who survived to
come under medical or surgical treatment, had a
comparatively good chance of recovery. Operations
on the chest at that time were limited practically to
the draining of empvemata, but even they were often
too long delayed. When experience of work in
•■advanced units became better known, it was ap-
preciated that the mortality of chest cases was really
high, and that, with very few exceptions, only those
with the more trivial types of wound lived to reach
Base hospitals. Statistics taken during a big battle
showed that the mortality in the more severe types
of chest wounds was very high, in fact, in the case
of so-called “ open ” or u sucking ” wounds, unless
immediate operation was performed, it was quite
exceptional for patients to get to the base at all.
Thcjr died in advanced hospitals or en route. It
was long before the general body of surgeons recog-
nized that, if great loss of life was to be avoided, such
cases must be treated on principles which govern
operations on wounds of other parts of the body.
The statistics referred to showed that, of 1,500 cases

2 is

214 EARLY TREATMENT OF WAR WOUNDS

diagnosed as penetrating wounds of the chest, roughly
30 per cent, were included in this dangerous category.
The result of active and common-sense treatment,
which has now reached a high state of efficiency,
is that, instead of a practically negligible number
being despatched from the casualty clearing stations,
the best operators send over 70 per cent, of such
patients down the line with every prospect of being
at least useful citizens. Some of them have returned
to full duty again.

The term “ penetrating ” is used to indicate actual
injury of the pleural or mediastinal areas of the chest,
whether the missile has pierced these or not. Tan-
gential wounds of the parietes, especially if the ribs
are involved, may be accompanied by intrapleural
lesions almost as severe in effect as are those of
wounds made by missiles which actually traverse the
pleural cavity or lung. It is, therefore, necessary to
include these tangential wounds under this heading.
Injuries confined entirely to the parietes will not be
discussed.

Penetrating chest cases, which arrived at casualty
clearing stations during the period covered by the
statistics quoted above, were in the proportion of
about one to forty wounded men.

Chest wounds, at an early stage, divide themselves,
from the clinician’s point of view, into four classes :
(a) the largest group, cases which do not require
operation ; (6) cases which demand operation at the
earliest possible moment ; {c} a class intermediate
between (a) and (b), in which the size of the wound
or the severity of the symptoms makes decision as

to immediate treatment a very difficult matter ; and
(d) moribund cases, who probably succumb within a
few hours of admission to the casualty clearing
station.

Treatment on Arrival.— The majority of “ pene-
trating chests arrive at the casualty clearing
station in an exhausted and frequently alarming
condition. They should be rapidly examined, put to
bed, and propped in the most comfortable position,
which is usually the semi-recumbent. They must
then be carefully warmed and stimulated. If they
are excited and anxious a sedative should be given
hypodermically. Omnopon is, for many reasons,
superior to morphia in such cases. If an open
“ sucking 55 wound is present, it should be made air-
tight by sutures which include both skin and muscle,
or by gauze plug fixed by a long strip of broad ,
adhesive strapping. Alarming symptoms usually
gradually subside within an hour or two*

Further active treatment depends on the severity
of the symptoms which persist or develop, and on the
size and character of the wound.

Cases requiring Immediate Operative Intervention* —
Severe respiratory distress may persist, owing to the
amount of hsemothorax or hsemoperieardium present.
Persistent severe pain is probably due to irritation of
pleura or pericardium by a rough foreign body or
fragment of rib* Pericardial pain may be referred
to the shoulder or side of the chest, one or both* A
foreign body actually imbedded in the lung or heart
does not usually give rise to such pain. The dia-
phragm is fairly frequently injured and irritated by

216 EARLY TREATMENT OF WAR WOUNDS

such foreign bodies projecting into it, and painful
dyspnoea is then apt to be intense. Increase of
respiratory distress may be due to increase of the
hemothorax, or to rapid development of infection of
the blood-clot, especially by gas-forming organisms.
More rarely it is due to increase in size of a hernia
through a rent in the diaphragm. AH these conditions
demand immediate operation, and every effort should
be made to get the patient into condition fit to
undergo it.

Moribund cases which arrive at casualty clearing
stations die chiefly from the effects of haemorrhage
and shock. During periods of severe fighting little
can be done for them. “ C'est la guerre ” / During
quieter times a small number may be saved by
transfusion of blood, which should be done on the
operating table, so that if haemorrhage recurs as a
result of the transfusion it may be tackled without
delay;

Necessity to comhat Sepsis. — As in wounds of other
parts of the body, no case can be pronounced free
from the danger of sepsis. The earlier it develops,
the more serious it is likely to be if not nipped in the
bud. Many patients who are sent to the Base
without operation, in apparently favourable con-
dition, reveal sepsis on arrival there, or develop it
soon after, and mortality is high amongst them.
Liability to early and fulminating sepsis depends
chiefly on the size of the wound, especially of the
entrance wound, which again depends on the size
and nature of the missile. Sepsis has been the cause
of early death in most of the “ sucking ” wounds

PENETRATING WOUNDS OF THE THORAX 217

which reach the casualty clearing station. Much
success has attended efforts to prevent this, in eases
which were previously thought to be beyond "the
reach of surgical aid.

Cases of “Closed" Hemothorax. — Most patients
with punctate entrance and exit {E. and E.]» or
through and through (T, and T,], bullet wounds, and
wounds caused by lodging shrapnel balls or small
pieces of shell, who survive until they reach the
casualty clearing station, usually recover from their
initial symptoms fairly quickly. All of them require
careful watching. Many cases of E. and E, bullet
wounds cause but slight anxiety. There may be
little or no haemothorax. If the hemothorax does
not reach higher than the nipple line and shows no
sign of increasing, and if there is no evidence of
infection, such eases may be sent to the Base without
danger in the course of three to six days, according
to the amount of accommodation available in the
casualty clearing station. In any case of hemo-
thorax, if the high temperature, quick pulse, and rapid
respiration, which are usually present during the first
twenty-four hours or so, do not subside, recourse
should be had to the use of the exploring syringe, and
the fluid removed should be tested bacteriologically .
A crimson-purple colour of the froth in the barrel of
the syringe, and a foul odour of its contents, are
sufficient proof of anaerobic infection. The with-
drawal of foul-smelling gas alone is conclusive
evidence. Such examination should be made every
day, or every second day, according to the nature of
the case. The test is by no means infallible, because

218 EARLY TREATMENT OF WAR WOUNDS

sepsis may develop in islands or areas of the clot or
fluid which are not tapped by the needle. Increase
of pneumothorax, or development of resonant patches
in previously dull areas, should make one suspicious
of gas infection, and if, in such a case, other symptoms
pointing to infection are sufficiently prominent,
operation should be undertaken without waiting for
bacteriological confirmation. If for any reason, such
as the presence of severe wounds elsewhere, a case of
limited aseptic hsemothorax has to be kept in the
casualty clearing station, there is, in most cases, no
need to aspirate the chest, as the fluid is usually
absorbed fairly rapidly. If it is not, aspiration
should be done and bacteriological examination
made. In some eases there is found a mild infection,
which repeated aspirations may cure.

If the hsemothorax is a larger one, the patient
should be kept for a correspondingly longer period.
During the first three days, aspiration may be required
at any time in order to relieve symptoms of distressed
respiration, even although no infection be present.
Fresh bleeding, rarely, or effusion of serum, may
increase the intrapleural pressure. The aspiration
should be done slowly, and no more fluid removed
than what is necessary to make the patient reasonably
comfortable. Aspiration of a large quantity during
this period may cause haemorrhage to recur. If
urgent symptoms develop again, it is probably best
to operate at once, make a large opening in the chest
wall, clear out the pleural cavity, control the source
of the haemorrhage, and close the opening completely.
In other cases, after the critical three days have

PENETRATING WOUNDS OF THE THORAX 210

passed* the bulk of the fluid may be withdrawn,
preferably with replacement by air or oxygen. If
the patient is fit to travel to the Base, however, he
should be sent there before this u final 33 aspiration
is done.

These remarks regarding sepsis, the use of the
exploring syringe, and other procedures* apply with
greater force to cases of large haemothorax than to
those of minor degree.

As already stated, between cases with “ closed ”
chest wounds and those with “ open, 3 * possibly

sucking 33 wounds* there exists a number, fairly
large, in which decision as to treatment is fraught
with great difficulty and anxiety. The possibility cf
giving relief to the patient and preventing a pro-
blematical development of sepsis, must be weighed
against the danger which the operation necessary for
such a double purpose involves. Statistics show that
the ordinary empyema operation in these early cases
is attended by a very high mortality. In many early
cases more thorough cleansing operations, followed
by complete closure, have been attended by very
striking success, but a sufficient number of cases has
not yet been recorded to permit of reliable judgment
being made. One cannot help thinking that the more
frequent use of blood transfusion in the early stages
will lead to better results* and permit of successful
radical operation in a greater number of “ inter-
mediate 53 cases.

The mortality from sepsis at the Base appears to
indicate interference, in a larger number of eases, at
the casualty clearing station. The small piece of

220 EARLY TREATMENT OF WAR WOUNDS

shell, or the shrapnel ball, has apparently a more
deleterious effect than is thought possible by those
who light-heartedly remark that “ it can*t do much
harm*”

Severe Open Wounds,— There now remains a large
number, 25 to 80 per cent., of eases which, from the
nature of their wounds, demand operation at the
earliest possible moment. Operation is performed in
such cases with a two-fold desire — to tide the patient
over the acutely dangerous period brought on by
hemorrhage, collapse of lung and displacement of
organs, and to prevent the onset of sepsis. Mere
closure of the opening in the chest wall will attain the
former object, unless as already pointed out, the
position and character of the lodged missile, or
displaced fragments of rib, cause too great interference
with the function of vital organs. But mere closure
of the wound will in no measure prevent development
of sepsis, which in this class of case is usually ex-
tremely virulent and lethal* Therefore, thorough
excision of lacerated tissue and removal of blood-
clot and foreign bodies are as essential to ultimate
success here as in other parts of the body. The in-
cidence of sepsis at different stages, with the resultant
mortality, in the earlier days of the war, when com-
pared with what occurs now, furnishes complete
justification for the radical operation in severe cases*
The operation must needs be attended by a high
mortality. The decision as to the proper time for
its performance should result from the close colla-
boration of a skilled surgeon, a shoek specialist, and,
when possible, a level-headed, enterprising physician*

PENETRATING WOUNDS OF THE THORAX 221

Many publications have been made recently on the
treatment of these severe cases, and to these atten-
tion is recommended, (See references, page 229.)

Major J. Anderson, D.S.G*, classifies the cases
belonging to this group as follows

(1) Wounds caused by large irregular fragments of
high explosive shell, which have lodged in the thorax.
These are almost always associated with (a) clothing
and infection carried in, and (&) open “ sucking ”
wounds of the chest wall.

(2) Tangential wounds of the thorax, enfilading the
ribs and driving portions of the bone, etc., into the
pleura and lung.

(8) Entrance and exit bullet wounds, in which the
exit wounds are explosive in character.

Those belonging to the first variety are most serious
and fatal* Those belonging to the last are probably
least so, and respond most favourably to excision and
closure of the wounds, because infection of the pleural
cavity in them is caused by secondary advent of
organisms through the open wound*

Discussion of the extraordinary variations of the
lesions, which occur in the thoracic viscera, and of the
positions which foreign bodies take up, is not necessary
or desirable in such an article as this. Suffice it to
say that they may be extraordinarily simple and easy
to deal with, or they may demand great skill and
dexterity, combined with ample courage, on the part
of the surgeon. Fortune lias shown her favour for
the brave on repeated occasions. Immediate fatal
haemorrhage, as the result of removal of a large piece
of shell from the root of the lung, need not deter the

222 EARLY TREATMENT OP WAR WOUNDS

surgeon, keen to accept his responsibilities, from
tackling the next apparently similar case. In the
second case the piece of shell may not be blocking a
hole in the pulmonary artery ! The heart, as well as
the lung, has shown itself to be tolerant of manipula-
tion and attack of the surgeon’s knife. There must
be a considerable number of men alive to-day who
have had this part of their anatomy penetrated by
bullets and other missiles during this war. Foreign
bodies, in the wall or cavity of the heart, have been
removed with wonderful ease and success on several
occasions. Successful suture of penetrating wounds
has been still more frequent.

X-ray localisation is of inestimable value in cases
where bullets or fragments of shell have lodged in the
chest. It indicates, often, that a route of approach
other than through the wound must be chosen, and
of course facilitates precision and prevents unneces-
sary manipulation and loss of time during the intra-
thoracic part of the operation.

Choice of Anaesthetic.— As there is considerable
likelihood of inflammation appearing in the contra-
lateral lung, the use of ether should be avoided when
possible. IP a general anaesthetic is used, nitrous
oxide gas and oxygen is the one to be preferred.
Many of the cases can be done perfectly easily and
painlessly after local infiltration of the tissues round
the wound or site of fresh incision, aided by blocking
of the intercostal and other nerves supplying the
part. The technique necessary for success in most
cases is easily acquired. The patient should be
given a hypodermic dose of omnopon or morphia

\

PENETRATING WOUNDS OF THE THORAX 223
half an hour beforehand* (Omnopon § grain and
scopolamine tiit grain, Hoffmann, la Roche & Co*, or
morphia J grain and atropine grain.)

Technique of Operation — Rapidity and thorough-
ness are imperative. It is important to obtain ease
of access to all parts of the pleural cavity. Since
drainage is not made at the end of the operation,
there is no need to make the opening low down. If
the wound is high up on the front of the chest or
involves the body of the scapula, a fresh wound should
be made, but otherwise the approach is obtained
through the wound made by the missile, after excision
and possible enlargement thereof. The opening should
be large enough to admit the surgeon’s hand freely,
and to enable him to inspect every part of the cavity.
If a fresh incision is required, it will probably be
found most suitable, as a routine measure, to remove
four to five inches of the fifth or neighbouring rib
in the infra-axillary region. If several adjacent ribs
are involved in the smash and require removal,
usually there will be adequate access procured through
the original wound, unless the subscapular ribs are
the ones implicated.

The original wound or wounds are excised, en
masse if possible — skin, subcutaneous tissue, muscle,
bone and edges of pleura, in one piece. The pleura
should be preserved as much as possible. If this
wound does not give suitable access to the pleural
cavity, it is stitched up, layer by layer. If the
pleura has been destroyed too much to allow ap-
position of its edges, then the muscles are sutured,
catching up the remnants of pleura so as to

(

224 EARLY TREATMENT OF WAR WOUNDS

present as smooth a surface as possible to the
expanding lung and to prevent pocketing. If both
pleura and muscle are shot away in great extent,
the hole can still be covered over completely, by
sliding a flap, possibly containing muscle, and
suturing completely*

Then a fresh incision is made through the chest
wall over the fifth rib, which is resected, and the
pleura-periosteum is divided by a clean cut along the
middle of the bed of the rib* It may be necessary,
in order to get still freer access, to divide the rib above
or below*

If the lung is collapsed, the edges of the wound are
strongly retracted* A self- retaining retractor is
found to be of considerable value. The fluid blood
is siphoned off through a wide drainage tube or the
patient is tipped over in order to let it run out*
Blood-clot is scooped out with the hand. Swabbing
out the blood takes up too long time and should not
be done except to remove the last ounce or two*
Isolated adhesions may have to be broken down or
divided in order to get the pleural cavity thoroughly
cleaned, but, if not recent, they should be left intact.
A rapid survey is made of the interior of the cavity.
The lung is dealt with as is found necessary — seized
and pulled out, foreign bodies or fragments of rib
removed, or the part where they lie is clamped, excised
and sutured ; the track in the lung is cleaned out,
possibly rubbed with antiseptic, and bleeding con-
trolled by ligature, suture, cautery or gauze plug ;
gangrenous or very badly lacerated lung is excised
and the part sutured, and so forth. Special forcipes

PENETRATING WOUNDS OF THE THORAX 225

(£.g* Duval’s) and clamps are not really necessary*
The use of a cotton glove or gauze on the hand which
controls the lung will make manipulations easier*
If accessible, foreign bodies imbedded in the spine or
mediastinum are removed and the bed in which they
lay is chiselled or gouged away or cleaned out and
antisepticized* The pleural cavity is then wiped dry
and the wound in the chest wall closed completely.

If it is unlikely that immediate expansion of the lung
will cause haemorrhage, the air in the pleural cavity
should now be slowly aspirated, completely or parti-
ally according to the extent of the pulmonary lesion*

If the lung is adherent all round the wound, the
latter half of the operation entails simple removal
of F. B., excision and suture, or cleansing and drain-
ing the track*

The application of the mastisol dressing referred
to in chapter VI, page 1C5* is of value in the after
treatment by giving extra support and preventing
strain on the sutured area*

Wounds of the Diaphragm. — If the diaphragm is
torn, repair of the rent, by trimming and suture, should
be the first step of the intrapleural procedure after
the cavity has been cleared of fluid blood and clot*
Wounds of abdominal viscera frequently accompany
such an injury and a variable amount of prolapse
into the pleural cavity may be present. Some such
cases may require treatment through an anterior
abdominal incision, but others arc more readily
treated, especially if the periphery of the diaphragm
is affected, by enlarging the original wound, resecting
a rib or ribs, dividing the diaphragm parallel to its
15

226 EARLY TREATMENT OF WAR WOUNDS

fibres downwards from the rent in it, and then pro-
longing the incision downwards and forwards to any
required extent in the abdominal wall In such
cases the lung frequently escapes injury and, after
removal of fluid blood and clot, the pleural cavity
can usually be closed off (and aspirated) before the
abdominal part of the operation is undertaken, by
suturing the diaphragm airtight to the chest wall
around the upper periphery of the original wound.
It is astonishing to what a height and at what tension
the diaphragm can be sutured in this way with
practically no subsequent distress to the patient*

In several cases in which the lower ribs have been
blown away, the diaphragm has been used in this
manner in order to close the pleural cavity* The hiatus
in the chest wall is then filled up by sliding a flap.

In multiple injuries the treatment of a “sucking ”
chest wound should always take precedence*

Routine Aspiration during the Period of After-
treatment — Physical signs are apt to be misleading
as to whether fluid is collecting in the pleural cavity
or not after such operations* Routine aspiration
should therefore be made, within twenty* four hours
of operation and at least every second day thereafter*
Resection of rib and drainage will thus be rendered
unnecessary in many cases* Even although definitely
purulent fluid tends to accumulate, repeated aspiration
is often all that is necessary to effect a cure* If, how-
ever, severe constitutional symptoms appear, a drain-
age operation should be carried out.

Evacuation to the Base* -Such cases should be
retained at the casualty clearing station if possible

PENETRATING WOUNDS OF THE THORAX 227

until they arc able to be out of bed and move about
the ward without detriment. Even in very busy
times they must be kept until it is fairly certain that
a secondary drainage operation will not be required.

The following are the results obtained by Major
J. Anderson, D.S.O : {a) during two months in 1917,
and ( b ) during two months in 1918.

(a) Taken from Major Anderson’s paper in British
Medical Journal t November 3rd, 1918 ;

Total cases of Group B. operated on and chest wall

closed ........ 58

Evacuated apparently doing well . . , * 44

Died ......... 14

Required secondary operation (drainage, etc,) . .12

Number of cases with multiple wounds , , .29

( b ) Report sent by Major Anderson to author.

“ Cases of G.S.W. of Chest treated from April 2nd,
1918, to June 2nd, 1918).

“ In order to compare the results in the type of cases
with those which I published in November 1917, I
have collected and recorded these over a similar
working period of two months in this year,

“ Wounds of chest wall not opening pleura arc not
included in this record.

Case*.

** Total number of patients, with penetrating wound of
chest (4 deaths occurred in pre- ope rati on ward) , 74

Caused by bullet . v , . .17

Caused by shell, bomb, etc, . .57

Operative procedure in , . . . . .55

Number of these cases with multiple wounds . , 34

Cases with wounds of thorax and abdomen, involving
and requiring suture of diaphragm , , *20

Cases with foreign body lodged in lung, or chest cavity 17
Foreign body removed . . . . , .14

228 EARLY TREATMENT OF WAR WOUNDS

“ The majority of eases were operated on between
eight and twenty hours after wounding.

“ Results :

« Cases evacuated to Base apparently well * * 44

Died at Base (Sub-phrenic abscess and shock) « * 1

Required secondary drainage of'empyema at base and

recovered * ♦ * ^

Under treatment (one with secondary drainage for B.

welchii and strep, infection) . . . « * 2

Died at casualty clearing station after operation * 9

“ Analysis of Deaths :

“Chest abdomen * . . * * &

Peritonitis *..*•*■ 3

Septic lung «■••••' 2

Infection of ha? mo thorax caused by hsemolysing strep*
toooccus, multiple, E. and E, bullet* (No other
case of Strep* H. found) . . * * • 2

Pure chest, shock, E. and E. bullet, involving lung and
root of neck .,*■**■ 1

Both chest cavities and cervical spine • » 1

One German prisoner went to base with open thorax, local*

“ Remarks . — There was an unusually large pro-
portion of shell wounds and of chest-abdominal
injuries,

“ Most of open thorax cases arrived with temporary
suture and travelled well to casualty clearing station,
when compared with purely abdominal cases, who
travelled badly* Nearly every case required aspira-
tion, some six or seven times.

“ Prevailing infection, B. Weichii.

“ All except two cases remained closed and required
no secondary operation except aspiration.

PENETRATING WOUNDS OF THE THORAX 229

REFERENCES

{1} Duval, Les plates du poumon f 1917*

(2) Papers on Surgical Treatment of Gunshot Wounds of the

Chest, in British Medical Journal , November 3rd, 1917.
By Major J, Anderson, D.S.O., Major J. E. H, Roberts, Captain
J, G, Craig, and Captain F. J. Hathaway.

(3) “ Remarks on Penetrating Gunshot Wounds of the Chest, and

their Treatment,” British Medical Journal , December 15th,
1917. By Colonel G. E, Gask, D.S.O. and Captain K. D.
Wilkinson.

(4) “ War Surgery of the Chest,” British Medical Journal t

January 26th, 1918. By Major A. L. Lockwood, M.C., and
Colonel J. A. Nixon.

CHAPTER IX

INJURIES or THE SPINAL CORD

This chapter, except in a few minor details, is identical
with a paper written two years ago. One might say
that there has been too much stagnation in this
branch of war work. Possibly this may be due to
an overpowering sense of hopelessness in treating
the majority of war injuries of the spinal cord, but
on the other hand late observation has revealed
occasional surprising improvement in cases which
appeared to be doomed to life-long paraplegia. While
ill-considered interference cannot be too strongly
deprecated, yet it is probable that, if early operation
is carried out, such cases will recover more quickly
and completely* and an appreciable proportion of
those who, without operation, would remain unrelieved
of their miserable incapacity may become partially
or even wholly restored, lie that as it may, the fact
remains that one meets, in several quarters, great
reluctance to tackle such injuries by operation. One
knows that operations on tins class of cases are pro*
ductive of striking results in a proportion less than
in any other type. Hut the results of treatment
without operation arc apparently no better.

Only a few of the injuries directly due to a bullet

N

INJURIES OF THE SPINAL CORD 231

or shell fragment can be compared with those met
in civil practice. The outlook seems to be that
operation in all but undoubtedly hopeless cases will,
although attended by many failures, give quicker
improvement and more complete recovery, when
that is possible, than a less active lino of treatment
in which the abnormalities surrounding or actually
in the spinal cord are not removed. Recovery of
function is obtained in such a small proportion, how-
ever, that only the most hopeful cases should be
tackled when great pressure of work exists.

To judge from the greater vulnerability of the
spinal cord, its lesser capacity for recovery, and from
the anatomical arrangement of the narrow spinal
canal, owing to which displacement of bony fragments
or other abnormalities arc apt to produce more
deleterious effects on the cord, it might have been
thought that the general desire to interfere in spinal
injuries, and to prevent secondary complications,
would have been as great as that shown with regard
to cranial injuries. This has not been the case.
The technical difficulties of the classical operation
of laminectomy, the loss of blood entailed by it
occasionally under general anaesthesia, and the
doubtful results of deferred operations, seem to be
the chief factors in preventing patients, suitable for
early operations, being treated on principles similar
to those which govern treatment of wounds in other
parts of the body.

In late cases the patients arc usually in poor con-
dition, and may suffer from bedsores, or from pul-
monary or urinary complications, while the affected

/O

232 EARLY TREATMENT OF WAR WOUNDS

area has become obscured by masses of fibrous tissue*
In early eases the presence of fractured lamina;
usually makes the operation a comparatively simple
one* easy to perform under local anaesthesia* and,
with the use of good adrenalin, practically bloodless.
Pulmonary complications arc not predisposed to, or
influenced by, this anaesthetic. Operation in the
early stages can, in fact, be done with extraordinarily
little upset to the patient* Out of a large number,
I have never seen a death which could be said to
have been hastened by it.

As already indicated, the fact that so many cases
improve without operation, in spite of the abnormal
conditions surrounding the cord, would lead one to
hope that more rapid and material improvement
would result from early operation to remove these
abnormalities, and that some cases, otherwise per-
manently paraplegic, would be sensibly relieved.
The cord, to a greater extent than most parts of the
brain, is deleteriously affected, and retarded in
recovery, by pressure of fragments of bone, foreign
bodies, and other debris* There seems reason to
believe that, if capable of recovery, it responds well
to prompt removal of these unnatural conditions*

In a casualty clearing station, however, during a
“ push,” a hurried selection of cases for evacuation
must be made, and only those which are most favour-
able for immediate treatment must be retained. In
all cases sent by ambulance train, the urine should
first be drawn off, if retention be present*

Some general considerations in making the decision
as to operation are here mentioned.

INJURIES OF THE SPINAL CORD 233

There are three types which arrive at a casualty
clearing station showing paraplegia— one in which
the symptoms are due to local concussion, another
in which the cord is organically severed, and a third
in which paraplegia has developed since the injury.

The paralysing effects of local concussion are often
very marked. This may be caused even by the
flight of a missile close to but outside the spinal
canal ; for example, temporary paraplegia may
follow the passage of a rifle bullet from side to side
between the spinous processes. In such eases the
paralysis usually begins to clear up within a few
days. If no sign of return of function occurs within
nine or ten days, the question of operation for
removal of blood-clot, or possibly of depressed
bone, arises. This usually must be decided at the
Rase,

If, on the other hand, a rifle bullet, causing a
through and through wound of the trunk, traverses
the spinal canal, the cord is usually hopelessly pulped.
An estimate should, therefore, be made of the probable
track of the bullet, bearing in mind that the position
of the patient during examination may not corre-
spond to that in which he was hit.

It is obvious that cases of complete, sudden para-
plegia should not be kept in the casualty clearing
station, if they are otherwise fit to travel.

If, however, the paralysis has developed since the
man was wounded, it is probably due to pressure
from blood-clot (when it is not likely to be absolute),
or to displacement of fragments of bone during move-
ment. In both these eases early operation may be

234 EARLY TREATMENT OF WAR WOUNDS

indicated, but in the latter only if X-rays show a
minor degree of displacement. If displacement is
great, the cord is probably pulped*

If conduction, either motor or sensory, is present
in the affected part of the cord, when the patient is
admitted to the casualty clearing station, it is
usually found that fragments of bone are pressing
on the cord, or that the missile causing the injury
is in close relationship to it, and will probably have
carried in sepsis. There may or may not be partial
division of the cord. A missile with momentum
sufficient to carry it far past the cord usually pro-
duces complete early paraplegia, even although it
may not cause complete section. If then X-rays
reveal fracture, or the presence of a foreign body
partly or wholly in the spinal canal, operation should
be done at once, with the quadruple purpose of re-
lieving pressure, cleansing the wound, restoring
normal circulation as soon as possible, and, thus, of
combating sepsis.

In some cases pain is so excessive and uncon-
trollable by other means, that, whatever the amount
of paralysis, operation is imperative in order to
relieve the pressure on the nerve roots.

In a considerable number of cases, spinal injury
is so extensive in itself, or is associated with other
injuries of such a nature, that when the collective
results are computed, it is extremely doubtful whether
it is justifiable to take up the time of the surgeons
to the exclusion of more hopeful eases. Of course,
whenever possible, it is desirable, from a humanitarian
or family point of view, to treat the wound on general

V

INJURIES OF THE SPINAL CORD 235

principles, so that the patient may have a chance of
reaching home alive.

Selection of Cases for Operation —Roughly speaking,
it may be said that operation is indicated or advisable
at a casualty clearing station : —

(1) In the presence of incomplete paralysis of
motion or sensation below the lesion, especially,

{2) If X-rays show displaced fragments of bone or
the presence of a piece of metal in or near the cord.

(3) When the symptoms of paralysis have deve-
loped some time after the infliction of the injury,
unless due to inflammation, in cases which have
been “ lying out,” when operation is practically hope-
less.

(4) When pain, due to pressure on nerve roots, is
excessive and uncontrollable.

(5) In very exceptional and ultimately hopeless
cases, when the character of the wound is such that
sepsis, although not already evident, is otherwise
likely to develop and cause rapid death, and it is
important to keep the patient alive as long as possible.

In all other cases it is better, when feasible, that
the patient should be evacuated without delay.

In cases which are retained for more than a few
hours in a casualty clearing station, urotropine
should be given as a “ routine ” in an attempt to
prevent cystitis. The greatest care must be exercised
in performing catheterization.

Certain Operative Details. — (1) Local anaesthesia,
by infiltration down to and including the periosteum
of the laminae and articular processes, is as effective
as in a trephining operation, and even more easily

(

236 EARLY TREATMENT OF WAR WOUNDS

carried out. The patient should receive a preparatory
dose of morphia or omnopon-seopolamine, sufficient
to cause drowsiness. It is rarely necessary to use a
general anaesthetic at any stage of the operation,
unless the track of the missile is followed into non-
ana-sthetised tissues. A few whiffs may be given
if the patient complains much of the pain of the
injection, but the latter should be gone on with during
the administration. Adrenalin renders the field
practically bloodless.

(2) If the wound is in or near the mid-line, it
should be carefully excised down to the bone, as in a
trephining operation. If the wound is well to one
side, a fresh, free incision should be made in the
mid-line. This is sutured at the end of the operation.
The track of the missile is cleaned, antiscpticiscd,
and used for drainage purposes.

(3) Set operations should be avoided. A typical
laminectomy is rarely indicated. The laminae can
usually be nibbled away, as is done in many cases of
trephining for depressed gunshot fracture, until
healthy dura is exposed all round behind the injured
area. All obstruction to the easy removal of frag-
ments should be removed before any attempt is
made to lift them out. The greatest delicacy should
be exercised, especially if movement of these frag-
ments causes pain or twitching. One of the greatest
advantages of local anesthesia is that the patient
is capable of feeling such pain. This fact may pre-
vent further gross injury to the cord.

.(4) If the wound is not sutured, if the dura has
been opened, Carrel’s method of after-treatment,

INJURIES OF THE SPINAL CORD 237

with the patient lying on one or other side, should be
carried out. The rubber tubes should be stitched
to the muscle so that they may not become displaced
and press on the cord. If the dura is unopened a
gauze pack may be used.

It will be seen that the operation, in cases suitable
for it* is on the same plane with trephining the skull
in gunshot injuries, both as regards technique and
indications for dealing with dura, etc.

(5) In cases retained in the casualty clearing
station, the question presents itself as to whether
suprapubic drainage of the bladder should be done.
If operation on the spine show r s that early improve-
ment is to be expected, it may be advisable to post-
pone drainage of the bladder. In any case, if cystitis
threatens, drainage is indicated.

CHAPTER X

COMPOUND FRACTURE OF THE FEMUR

The principles of treatment here described apply
equally to compound fractures of other long bones,
except that, for various reasons, amputation is
indicated less frequently in fractures of the upper
than of the lower extremity. Sepsis in the upper
extremity is, on the whole, less virulent, radical
conservative operation is frequently much easier and
produces less shock, and the general condition of the
patient is better able to withstand the longer operation
and the greater strain during convalescence, while it
must be remembered that an artificial lower limb is
comparatively more satisfactory than one fitted to
the upper extremity. It must also be remembered
that, while a “ gunshot wound,” causing compound
fracture of the femur, was at one time looked upon
as one of the gravest of war injuries, a more wide-
spread appreciation of sound principles of early
treatment and a thorough application of these
principles, have led to a marked reduction on the
previously high rate of mortality and to improved
functional results.

In no class of cases is it more important that
adequate treatment should be begun early than in the

23S

COMPOUND FRACTURE OF THE FEMUR 239

large one comprising fractured femurs. The ratio in
which this injury occurs is roughly one in fifty to sixty.
It varies with the nature of the fighting. During an
advance the proportion is greater than during trench
warfare.

Experienced surgeons at casualty clearing stations
bear warm testimony to the great improvement which
has taken place in the early treatment of these cases
by regimental medical officers and field ambulances,
and reports from Base hospitals indicate that the
“ goods are now delivered in very good order ” from
the casualty clearing stations. In the hands of
skilled, experienced surgeons the immediate results
will probably be better still as an increasing number
of wounds are sutured primarily, or within a very few
days. Thus a prolonged, weary and precarious
convalescence will be avoided. A word of warning
must again be given against undertaking primary
suture until the essentials necessary for successful
early treatment of wounds are fully mastered* At-
tention to this warning will save many limbs and
lives.

The treatment carried out before the patient
reaches the casualty clearing station has been
described fully in Chapter I.

All cases of fractured femur should pass through
the operation theatre of the casualty clearing station,
because often, when thorough examination is made,
a case which, in the reception room, has appeared
comparatively simple and not likely to require
operation, shows that operation is urgently required.

/n

240 EARLY TREATMENT OF WAR WOUNDS

Unnecessary handling should be avoided, and
examination in the theatre alone is the best way of
ensuring this.

Anaesthetics to be used.— If wounds of other parts
of the body exist, a general anaesthetic is required.
If shock is, or has been, pronounced, especially if
amputation has to be performed, “ gas and oxygen
is the anaesthetic of choice. Spinal anaesthesia
(novocain 10 per cent,, 1-2 c.e*m*} is preferred by
some surgeons* If the patient has lost much blood,
transfusion should be carried out before the spinal
anaesthetic is injected. (See Chapter III.) Two or
more surgeons, according to the number of wounds
and the staff available, should deal with such cases.

General Considerations, — Although most cases ar-
rive in such good condition nowadays that they are
fit for operation without delay, yet in many the effects
of shock, haemorrhage and sepsis, are present to such
an extent that they require the employment of special
combative measures.

The general treatment of surgical shock and
haemorrhage has been discussed. Transfusion of
whole blood, in addition to warmth and rest, provides
the most certain restorative* Active haemorrhage
may require the use of a tourniquet, if not already
applied, and prompt removal to the theatre. Both
sepsis and shock require the administration of bicar-
bonate of soda, by various routes, in order to prevent
or neutralize acidosis*

One may well be pardoned for reiterating certain
points in connection with these injuries. All cases
of compound fracture of the femur should be disturbed

COMPOUND FRACTURE OF THE FEMUR 241

as Little as possible after their arrival at the casualty
clearing station. They should be sent without delay
to the pre-operation or resuscitation ward. They
should not be evacuated to the Base without first
passing through the operation theatre. Small super-
ficial wounds arc deceptive, and almost invariably
cloak much extensive damage of the deeper tissues.
When lodgment of the shell fragment causing the
damage has occurred, however small the aperture of
entrance, operation must not be postponed or omitted,
as may sometimes be done when an undistorted rifle
bullet is the cause. It must be appreciated, even in
the latter condition, that postponement of operation
incurs considerable risk, because a bullet which lodges
travels at a low velocity, and is more likely to carry
in sepsis than one whose momentum carries it through
the limb. Some such cases may be treated as simple
fractures.

Cases in which haemorrhage is taking place, or is
controlled by a tourniquet, will naturally be given
precedence in going to the theatre. Whenever
possible, inadequately splinted cases should go next,
or when this is not practicable the fixation should be
improved. If the limb is not put up in an efficiently
applied Thomas’s splint, no attempt should be made
to remove any clothing until after full anaesthesia has
been established, or until proper fixation has been
achieved.

When the patient reaches the operating theatre,
care must be taken that no increase of shock occurs
from unnecessary or rough handling. Probably the
soundest plan in all cases is to lift the stretcher on to

16

Fra, 23,— 'Diagram of rope and pulley apparatus for raising leg
from operating table,

apparatus shown in the diagram {%, 23). This simple
device frees the orderly from the arduous task of
holding up the limb during the whole period of the
operation. It can be easily unhitched when neces-
sary, Some surgeons advise to operate without
removing the Thomas’s splint and extension. Ade-
quate operation under such conditions can be done

242 early treatment of war wounds

the operation table, to anaesthetize the patient and
remove his clothing before the stretcher is taken
away. Thereafter, bandages and splints are removed,
and the nature of the injury investigated. In suitable
cases the limb is then raised from the table by the

COMPOUND FRACTURE OF TIIE FEMUR 248

only in the most simple cases* and therefore this
procedure is not recommended. Captain R. B.
Laurie has invented a special operation table which
provides excellent facilities for such cases.

In order to make quite sure of finding and removing
all septic material, it is advisable, when easily possible,
to project both broken ends of the bone out of the
wound. This manoeuvre can obviously not be carried
out satisfactorily when the splint is not removed.

The ordinary ritual for disinfection of the skin, and
the subsequent general technique, need not be
described.

The first step in the actual operation should be
excision of the superficial wound. It should then
be freely extended by incisions in the long axis of the
limb, or else in the direction of the main pockets,
unless the latter entails the division of important
structures. The full extent of the injury to muscles
and bone must be seen . The eye must be guide more
than the finger. It is only when a thorough survey
has been obtained that the operator is in a position
to decide the subsequent course he should adopt in
each particular case. The siae of superficial wounds
is no indication of the deeper damage. Most extensive
laceration of muscles and severe comminution of bone
very frequently underlie apparently trifling skin
wounds. The superficial incision must be very free.

The Question of Amputation, — The full extent of
the wound having been appreciated, the question
of amputation will arise in a proportion of cases. In
some hopelessly mangled limbs the decision is easy
even without previous incision. There are many

244 EARLY TREATMENT OF WAR WOUNDS

borderland cases where there is great difficulty in
deciding what is the proper course* It is a good plan
to hold an informal consultation in such cases.
Amputation should be performed : —

(!) When the main vessels, both artery and vein,
are divided, and collateral circulation has not been
established* In a few early cases, some form of blood-
vessel anastomosis can be performed, e.g. by intuba*
tion with a paraffin-covered glass tube, or a Tuffier’s
metal tube, in order to carry on the circulation until
collateral vessels have become dilated* The tube
gradually becomes occluded with blood-clot, and is
removed when pulsation in the part of the vessel
immediately distal to it has ceased (usually twenty-
four to seventy- two hours)- Suture is rarely possible.

(2) When gas gangrene is definitely established in
more than one group of muscles, or where, for ana-
tomical reasons, complete excision of any gas-infected
part cannot be carried out without entailing serious
disability.

(3) When either the main artery or vein require
ligature, and there is evidence of even a localized
patch of gas gangrene beyond the point of injury to
the vessel.

(4) When the sciatic nerve is hopelessly destroyed
for several inches.

(5) When virulent sepsis is already established in
extensive wounds, the patient being in low condition.

In eases where the general condition of the patient
is bad, especially as a result of shock-haemorrhage,
one’s leaning should be towards amputation, unless
blood transfusion completely changes the picture.

COMPOUND FRACTURE OF THE FEMUR 245

Involvement of the knee or hip joint does not by
any means necessarily call for amputation. The
same may be said of extensive laceration of muscles
and severe comminution of bone — if the circulation
is good, and there is no evidence of gas gangrene in
the wound.

When amputation is decided on, the circular or
modified circular method — as low down the limb as
possible — is the one which should be employed. The
“ guillotine ” operation is practically never necessary
or justifiable. In some cases, where speed is essential,
the amputation is made at the site of fracture, the
bone being trimmed at a later date. In ordinary
cases, when sawing the bone, a strong metal plate,
with a slot in it to admit the femur, is useful in
keeping muscles out of the way and in saving time.
For the purpose of preventing superficial necrosis of
the end of the bone, a layer of deep muscle fibres may
be stitched over it. If immediate primary suture is
not advisable, the dressing used is either a u pack ”
or Carrel’s method. Open amputation stumps are
ideal wounds for the application of a pack. The flaps
are drawn over the pack, and fixed by widely placed
sutures or by strips of adhesive plaster. A practical
point is, that room should be left between the skin
edges for drainage, when the sutures or strips of
plaster are being applied. Delayed primary suture
should be practicable in the majority of cases.

Conservative Treatment.— If conservative measures
are decided on, the operator must make up his mind
to perform a thorough operation on the lines described
in Chapter VI, page 153. It cannot be too often

246 EARLY TREATMENT OF WAR WOUNDS

emphasized that, in addition to the careful removal
of foreign bodies, the superficial wound must be
completely excised, and all badly lacerated fascia,
muscle, and soiled periosteum cut away* With regard
to the muscles, contraction alone is not a sufficient
guarantee of the necessary degree of vitality—
definitely bleeding muscular tissues must be reached
before one holds one’s hand* Great care must be
taken that the vascular supply of muscles previously
treated be not cut through during the later stages of
the operation* Once embarked on such an operation
there must be no half- measures* Most extensive
dissections may have to be carried out. There must
be no hesitation in cutting wide. One small piece
of devitalized muscle left in the wound may be
sufficient to render the whole procedure useless*

Bone fragments, unless completely separated,
should be removed only if they are badly soiled*
They should be thoroughly wiped or scraped, so
that all possible infection and blood-clot are removed,
and very lightly smeared with antiseptic paste. Com-
pletely detached fragments should be removed* If
possible the periosteum should be retained*

If a joint has been directly opened by a missile,
the operation is carried out as indicated in Chapter XL

Perfect haemostasis is essential* The whole wound
cavity may then be thoroughly washed out with saline
solution.

Immediate primary suture should be performed
if there is reasonable likelihood of asepsis having
been secured. This should be possible in the majority
of cases operated on within twelve hours of the injury*

COMPOUND FRACTURE OF THE FEMUR 247

Previous to closure, the whole surface and all crevices
of the wound may be rubbed gently with a solution
or paste of one of the recently introduced antiseptics
(flavine, brilliant green, or even Bipp, etc.). Great
care should be taken to obliterate dead spaces as
far as possible by well placed, not tight , deep sutures.
These must not interfere with the blood supply of
the parts. A drain should be inserted, for twenty-
four to forty-eight, hours, “down to but not into”
the area of fragmented bone. After the skin is
sutured, the whole wound area should be rubbed
over with picric acid solution*

In cases of doubt it is safer to use a paraffin or salt
pack. In two to four days, if no inflammation occurs,
delayed primary suture can usually be done.

Operation having been completed, all that remains
to be done is to immobilize the limb* Incomplete
fixation may lead to failure, in spite of the most
careful operative treatment. Thomas’s knee splint
is the one now used for the vast majority of cases.
A satisfactory splint for all eases of high fracture
associated with wounds of the buttock or perineum
has yet to be discovered. Abduction frames have
many drawbacks but are so far the best available for
transport. Unless great care is taken, pressure sores
develop rapidly when these are used.

Fixation by Thomas’s Splint* — A “ Thomas’s splint
outfit,” properly used, is the simplest and most
efficient method of obtaining complete fixation at this
stage.

The detail of the application is, shortly, as fob
lows : —

248 EARLY TREATMENT OF WAR WOUNDS

(1) The suspensory sling is removed from the
knee, and the limb is supported and pulled upon by
an orderly,

(2) Application of Extension Bandage.

It is not necessary to shave the limb. Paint the
entire circumference from the malleoli upwards,
sufficiently high to allow the extension to get a good
pull on the lower fragment, with a glue solution, of
which the formula is ■

Glue

Water . * - * * .50

Thymol i

Glycerin

Calc, Chloride aa, ...» - 2

(A shaving or small paint brush is used for applying the glue.
During a “ strafe ” a pot of this glue should always be kept ready
melted. The glue will become too thick after a time, and a little
water should then be added. The glued-on bandage can be re-
moved with warm water.)

Next place, lengthways, on both sides of the limb, a
strip of bleached calico bandage, and apply a roller
bandage over the whole,

(3) Application of Splint. — The ring of the splint is
passed over the foot and pushed upwards, until the
posterior part of the ring presses firmly against the
ischial tuberosity. In some cases of low fracture the
splint may be slightly bent opposite the knee.

(4) Tightening of Extension Bandages, — The sur-
geon takes an extension bandage in each hand and,
making strong traction, passes one of them over,
the other under, the lateral bars of the Thomas’s
splint. First one bandage and then the other is
thereafter passed round the notch in the cross-bar,

v3

COMPOUND FRACTURE OF THE FEMUR 249

a complete turn being taken in each case. The turns
are taken in opposite directions, and the last over-
laps the first. The ends are made secure by tying
a half- bow. This method of fixing the extension
bandages can easily be undone and adjusted again,
when necessary, without relaxing the pull on the lirnb.

Fig, 24. —Method of tying the extension bandage in fracture of the
femur so as to prevent slackening of the extension and loss of
time during adjustment. First pull on both bandages ; then
pull especially on A, fix* as in diagram and hold taut. Pull
on B ; take a turn round notch of splint over A and hold taut.
A may now be left loose. Tie loop knot with A on B.

When adjusting, hold B taut ; undo knot ; hold A taut
and slip to its own side. Pull on if and proceed as above from*,
substituting B for A*

(5) Application of Slings* — In cases where the
wounds are in such a position that it will be necessary
to remove the ham splint for dressing purposes,
slings formed by bandages or, better still, perforated
zinc strips, should be applied at this stage* The zinc

n

250 EARLY TREATMENT OF WAR WOUNDS

strips are thinly padded and covered with waterproof
material. They arc applied so as to leave the wound
clear, but at the same time support the fragments
when the supporting ham splint is removed- One
such sling should always support the lower fragment
and upper part of the calf.

(6) Application of "Ham” Splint — See page 57.
This should be padded to suit each case. Moss pads
serve the purpose well. Over these a sheet of jaconet
is placed to prevent soiling. The ham splint is now
slung to the side bars of the splint by three strips of
adhesive plaster — the adhesive side being next the
ham splint. This effectually prevents its lateral
movement. The posterior padding should be enough
to cause slight flexion of the knee. Sagging of the
thigh must be prevented also by suitable padding.

(7) Application of Anterior Thigh Splint. — This splint

consists of a piece of Gooch’s splinting applied
to the thigh, canvas side towards the limb: It

should extend from near the ring of the Thomas’s
splint to just above the patella. Before a “ push,”
a number of suitable lengths of Gooch’s material
should be cut. The whole roll may be sawn through,
and an orderly can cut off any breadth required.
The thigh splint is fixed by the bandage, which is
now applied to the limb from the ankle upwards.
This bandage encircles all the splints.

A bandage passing across the extreme upper part
of the thigh, from bar to bar of the splint, may be
necessary to prevent flexion of the upper fragment.
Care must be taken that any padding or small splint
used does not press on the main vessels.

COMPOUND FRACTURE OF THE FEMUR 251

(8) Application of the Footpiece.— The foot must
be supported at a right angle by means of a metal
foot rest, which is part of the outfit.

A Lt gutter ” of perforated zinc sheeting is fixed on
the footpicce. The foot, or gutter, is padded. This
arrangement allows free dorsiflexion of the foot, a
movement which the patient should be encouraged
to make frequently. The circulation of the limb is
thereby assisted. Rotation of the leg can be pre-
vented by various simple means, e.g. s by a strip of
sticking plaster fixed to one bar of the splint and
encircling the ankle,

(9) Two Stretcher Suspension Bars should be used
during Transport,— To one, the^more important, the
lower end of the Thomas’s splint is slung by two
pieces of bandage, one attached to either bar of
the splint. If no suspension bar is available, the
leg must be supported by some other means so that
the heel is carried clear of the stretcher. To the
other bar the upper end of the splint is slung as
shown, just high enough to make the ring press
very lightly on the tuber ischii. The sciatic nerve
must not be unduly pressed upon.

If the patient cannot be evacuated, the injured leg
must be slung in the wards. A simple method is the
use of two bandages, each passed over a beam of the
hut. The two ends of one bandage arc then tied
to the bars of the splint close to the ring. The ends
of the second bandage are secured to the bars at the
level of the foot.

Many modifications of this method of fixing
fractures of the femur have been introduced, but

sna

COMPOUND FRACTURE OF THE FEMUR 253

it still remains the simplest and not the least effi-
cacious.

Various forms of elastic or spring extension,
attached to the lower end of the Thomas’s splint, have
become popular. They are used with the object of
“taking up the slack” which may occur during
transport. They are of value only when the space
between the sole of the foot and the notch of the
splint is great enough to allow sufficient play of the
spring extension. When such elastic extension is
employed, a “ spreader ” should be used to carry the
lateral extension strips clear of the malleoli. The
strips should not pass round the lateral bars of the
splint.

Evacuation, — Many cases of compound fracture
of the femur may safely be evacuated as soon as
they have recovered from the anaesthetic. Before
evacuation the extension should always be inspected
— the bandages may require tightening or loosening.
A pad of wool may be required between the ring and
antero-external part of the thigh, so as to prevent
the ring from nipping the scrotum or slipping off the
tuber ischii.

In cases which have to be kept at a casualty clear-
ing station for more than twenty-four hours, the
superficial dressing should be changed before evacua-
tion, on account of oozing. Care also must be taken
of the skin pressed on by the posterior part of the
ring— it should be pulled up to change the point of
contact, and carefully dusted. Alteration of the
degree of elevation of the splint, or propping up the
patient, frequently adds to his comfort.

CHAPTER XI

WOUNDS OF JOINTS

Of wounds of joints sustained in the early part of
the war, the same tragic tale has to be told as of
wounds of other regions, and most strikingly so in
the case of the knee. The remarks made by a high
official in those days were only too true— that the re^
suits of wounds of the knee-joint were a deep reproach
to surgery — that surgeons were apparently impotent
to prevent loss of limb or of life. At a joint meeting
of French and British surgeons held towards the
end of the first six months of the war, it was painful
to hear, from representatives of both nationalities,
the reiteration of deplorable results— amputation —
death. At the record of a healed stiff joint one felt
almost inclined to cheer, while a story of movement
following an operation sounded like a fairy talc.
Now, what were fairy tales are commonplace, and
great is the satisfaction to those who were out in
the dark days of surgery ! It was demonstrated
shortly after that meeting that knee-joint injuries
responded well to treatment by excision, and nowa-
days, in competent hands, they yield as brilliant
results as any other class of wounds. The line of
treatment laid down in the Spring of 1915 has required
but little important modification.

254

255

WOUNDS OF JOINTS

Knee-joint, -Wounds of the knee-joint are more
frequent and liable to be more disastrous in their
consequences than those of any other joint. Their
treatment, therefore, will be indicated, and the
principles advocated can be adapted for other joints.

The enormous improvement in the treatment of
these cases is due chiefly to the early pre -inflammatory
stage at which most operations arc now performed
and the thoroughness with which they are carried
out, and to a great extent also to careful fixation
during transport. The evil effects of transport are
manifest to a greater degree in wounds of the knee-
joint than in most other types of wounds.

In many cases enforced delay in operation still
means absolute disaster. The nature of the injuries
and the virulence of the infection, coupled with the
unfavourable conditions under which the wound is
received, and the impossibility which may exist of
giving adequate attention to such injuries in the
early stages, still frequently give rise to such an ex-
ceedingly rapid inflammatory disintegration of the
joint and breakdown of the patient’s general resist-
ance that amputation is the only means of saving
the patient’s life. And at later stages, now as at
the beginning of the war, one must not be tempted,
because of the apparently quiescent and fairly pain-
less condition of the joint in certain cases, to post-
pone radical operation too long. In consequence of
the communication of the wound in the bone or
joint with the exterior, symptoms due to increased
tension in the part are absent, and therefore the
ordinarily described type of osteomyelitis or arthritis

ml

256 EARLY TREATMENT OF WAR WOUNDS

is not usually found. Patients with such injuries
usually have an obstinately high temperature* and, if
the cause of this and of the steady, but probably
insidious deterioration in the general condition can-
not be speedily overcome, amputation must be
done.

Willems and other Belgian surgeons have stimulated
the hope, however, that even in suppurating joints,
once the site of primary infection has been removed,
a useful movable joint may be obtained. The theory
on which their success is said to depend, that only
by active movements can a joint be thoroughly
drained, is so opposed to what surgeons have hitherto
believed to be the proper treatment, that caution in
adopting the method is excusable. But many old-
fashioned notions have been upset during this war
—one can remember well the incredulity with which
the results of excision of wounds were received, and
one cannot afford to neglect some of the brilliant
results which have been demonstrated by our Belgian
friends. It would appear necessary that, if success
is to attend such treatment, it must be initiated at
a very early stage— long before erosion of cartilage
has begun. It must not be instituted as a last resort
if it is to have a fair chance.

Types of Injury. — Certain common types of injury
may be summarized : —

(I) Cases of effusion without lodgment of the pro-
jectile in the joint — (a) In which it is uncertain
whether the synovial cavity has been traversed or
whether the synovial membrane has been merely

vT

WOUNDS OF JOINTS

257

traversed by a clean rifle bullet without injury to
the bones* (c) In which the bullet has cleanly
perforated one of the bones entering into the articu-
lation*

In connection with injuries of this class the common
association of effusion into an intact knee-joint with
a fracture of the shaft of the femur is to be borne in
mind*

Cases included in Class 1 are obviously subjects
for expectant treatment* If suspicion as to infection
arises, the joint should be tapped and the effusion
of blood or synovia examined bactcriologically. If
organisms are found, a usually successful plan is at
once to open the joint freely, wash out thoroughly
with saline solution or some warm non-irritating
antiseptic, and to close the wound carefully again*

Retained Missiles* — (2) Cases in which the pro-
jectile has lodged ; (a) within the synovial cavity,
and (6) in one of the articular ends. In (6), the
synovial membrane may not be injured, or only
slightly. Cases with more severe synovial injury
come under (3).

When a retained rifle bullet lies within the joint,
if the superficial wound is small and not inflamed,
it may be left for a few days, the joint being meantime
immobilized, but the better plan is to take no risks
and operate immediately.

Free fragments of shells or bombs, shrapnel or
distorted rifle bullets must be promptly removed.

Missiles imbedded in the Bones*— Clean rifle bullets
so situated as not to interfere with the movements
of the joint need not be interfered with at an early
17

/'■'V

258 EARLY TREATMENT OF WAR WOUNDS

stage. They may do no harm and have frequently
been left indefinitely. Fragments of shell come into
a different category. Here infective material has
practically always been carried in, and the retained
body must be removed by the shortest and safest
route. This may be by the original wound, although
sometimes the localizing skiagrams may indicate a
much shorter route, but, as the bed of the missile is
certainly infected, no advantage except that of direct
access is gained by a special incision. As the ex-
traction is commonly a matter of considerable diffi-
culty, the incision for the removal of impacted bodies
should be free. The bone surrounding the fragment
must be removed. The lining of the track and the
original superficial wound must be similarly dealt
with. Although after such treatment many cases
have been sutured completely with success, it is
safer, especially if the patient cannot be retained for
observation, to leave the wound completely open
for a few days, treating it with a paraffin pack, or
intermittent irrigation, as seems most suitable. A
gauze pack, if too tightly inserted, will favour
necrosis.

Open Wounds o£ the Joint. — (3) Cases in which
the synovial cavity has been more or less widely
opened ; (a) without damage to the articular surfaces,
and (6) where fissured fracture or slight comminution
of the articular ends of the bones co-cxists.

These require the primary measures which are
detailed later on, and often make remarkably good
recovery, especially if operated on within twelve to
twenty-four hours.

259

WOUNDS OF JOINTS

(4) Cases in which serious comminution of one or
more of the constituent bones has occurred*

Seriously Comminuted Fractures, — The majority
of cases in which gross comminution and soiling of
either lemur or tibia is present require amputation*
Severe compound T-shaped fractures of the lower
end of the femur can rarely be saved, and primary
amputation is frequently advisable* Extensive com-
minution of the cancellous tissue of the head of the
tibia or condyles of the femur may prove very danger-
ous, owing to the severe constitutional symptoms
which follow septic absorption from the injured spongy
bone* The early treatment of favourable cases
should include chiselling or gouging away infected
bone, if possible, followed by pack or Carrel dressings*

Fractures of the Patella* — Comminuted fractures of
the patella form a special class* The loose fragments,
sometimes amounting to the entire bone, should be
removed* They can often be removed en masse with
the wound of the overlying soft parts* If part only
ol the patella is removed, the raw surface of the
remainder should be carefully sawn or chiselled off.
The synovial cavity is flushed clean* The synovial
cavity can safely be closed in early cases by suture
of the synovial membrane and an attempt made to
obtain a movable joint, but free drainage is usually
necessary if infection has gained a hold.

This recommendation does not refer to the rare
eases in which an ordinary transverse fracture of the
patella has been produced by sudden muscular con-
traction following a bullet wound of the thigh, even
though the bullet should have traversed the knee-

260 EARLY TREATMENT OF WAR WOUNDS

joint. Neither should it be extended to some clean
puncture fractures of the bone produced by direct
passage of the bullet.

At Regimental Aid Posts and Field Ambulances —

In view of the importance of the treatment of such
injuries at regimental aid posts and field ambulance
dressing stations, it is well to elaborate what has
already been said on this subject. (Chapter I.)

Severe injuries should be treated on the same lines
as fracture of the femur, that is to say, they should
be put up in a Thomas's splint outfit. In small
penetrating wounds the limb should be fixed in a
long gutter splint, e.g a long Jones's fracture splint
or Gooch material, reaching from the tuber ischii to
the ankle, with a large graduated popliteal pad. The
upper and lower end of the splint should be fixed to
the skin by strips of adhesive plaster, of which the
lower may encircle the limb, but the upper should,
if applied at all, be applied spirally. The plaster
prevents displacement of the splint. A broad bandage
is then applied from end to end. Dressings and
bandages must be so applied that circulation of the
limb, or exudation from the wounds, is not interfered
with.

Movements of the joint may turn the scale in
favour of extension of sepsis, and may make all the
difference to the patient's future.

The question of amputation at this stage arises
only in cases where the limb is hanging on by lacerated
remnants— the bones, vessels and nerves being hope-
lessly destroyed.

The skin should be painted with picric acid in

261

WOUNDS OF JOINTS

spirit. Visible foreign bodies and absolutely loose
protruding pieces of bone and superficial blood-clot
should be removed. No other interference with the
wound is justifiable unless to stop haemorrhage. No
drains should be inserted. If a large gaping or valvular
wound exists* loose folds of gauze wrung out of weak
antiseptic* preferably i per cent, iodoform in paraffin,
should be inserted to prevent apposition of infected
surfaces.

At Casualty Clearing Stations. —The splendid results
which can be achieved make it desirable that all
cases requiring operation should be treated here
within a few hours of admission ; but, as this is out
of the question during severe fighting* a selection
must be made of cases likely to be able to travel to
the Base without serious risk.

This selection, so far as the injury of the joint
alone is concerned* will depend chiefly on the size
and position of the wounds, especially of entrance
wounds ; on the size and character of the missile,
especially if lodgment has occurred, and on whether
it is visible or palpable ; on the size of the wound
in the synovial membrane, and on whether it com-
municates freely with the surface wound so that
infection will occur easily ; on the amount and
character of comminution of bone ; on the presence
or absence of injury to large vessels ; on whether
intra-articular tension is present or absent ; and
finally, on whether definite sepsis lias developed or
not.

Cases for Transfer to Base during Severe Pressure.— That in t—*
If the wound of entrance is small* especially if clue to an undie-

/

i

262 EARLY TREATMENT OF WAR WOUNDS

torted rifle bullet, if there is no external evidence of a foreign body,
if there is no comminution of bone or injury to large vessels, if there
Is no painful tension, and if there is no inflammation, tho patient
may bo sent on to the Base, after thorough disinfection of the skin,
suitable dressing of the superficial wounds, and fixation of the limb,
the knee being slightly flexed, in a splint of proper length. The
“Thomas’s splint outfit is the best for tho purpose, and those eases
in which penetration of the synovial cavity is even merely suspected
should be fixed in it.

It may be noted her© that an “ open " wound of the baek of the
joint is usually less serious than a similar one on the anterior aspect,
possibly because, in the latter, sepsis is more likely to gain access
during transport*

Cases for Retention at Casualty Clearing Stations. — If tho super*

ficial entrance wound is large, even, e.g., like that caused by a
shrapnel ball, and especially if it communicates freely with the
synovial cavity, if there is a visible or palpable foreign body which
has opened the joint, if there is much comminution of bone, if there
is a hfcmatoma in the popliteal space or haemorrhage from a wound
there, if there is undoubted inflammation, the case should be kept
at the casualty clearing station for immediate operation.

On admission the limb should be dressed, fixed if
necessary in a suitable splint* and* if X-ray localiza-
tion is required, the patient should be sent to the
radiologist, who should take two skiagrams, one
anterb-posterior (toes pointing straight forward) and
one lateral* on the same plate if possible. This
method is probably the quickest and best in the
circumstances. The patient is then sent to the pre-
operation ward. The splint should not be removed
till the patient lias been anaesthetized. The strapping
of the splint permits examination of the wound
without moving the knee.

General Remarks regarding Operation,— In no other
class of cases is technique and judgment in early
treatment reflected so much in the results obtained,

268

WOUNDS OF JOINTS

The surgeon who exhibits the greatest care in tech-
nique, especially when removing foreign bodies and
infected tissue, whether of the soft parts or of bone,
gets the best results. Conservative operations on
gunshot wounds of the knee-joint, however, in order
to be successful, demand such care that they should
be handed unreservedly to the surgeon in the unit
who has demonstrated special skill in their per-
formance. Most of the failures are attributable to
want of appreciation of what is essential in totally
excising the soiled wound in such cases.

Excision of Wounds, — The ultimate object of
treatment of these eases is to secure mobility of the
joint. The primary object in the casualty clearing
station must therefore be to secure asepsis. The
surest and quickest way of doing this is to excise
completely, if possible en masse and with a scalpel,
all tissue which is definitely or probably infected.
This having been done, the wound remaining can be
treated on aseptic principles. This, of course, entails
the exclusion of all instruments, gloves, towels, etc.,
which may have come into contact with infected
parts. A large percentage of these wounds are
sutured, and heal by first intention. A suitable
plastic operation may have to be done. In many
cases it is advisable to provide drainage by tube or
rubber tissue 44 down to but not into ” the joint
cavity or bone fragments for twenty-four hours.

Although, in many cases, the wounds cannot be
closed, yet it is usually possible, for example after
excision of the patella, to suture the synovial mem-
brane of the front of the joint, especially if the

264 EARLY TREATMENT OF WAR WOUNDS

suprapatellar pouch is loosened from its upper and
anterior connections and pulled down. The lateral
parts of the synovial membrane may likewise be
undermined. Closure of the synovial cavity is of
very great importance.

Fixation, — Fixation of the joint during transport
is essential to success even in the simplest wounds.
It is found that the best method of ensuring this is
to put up the limb, slightly flexed, in a “Thomas’s
splint outfit,” just as in cases of fracture of the femur,
with the exception that the extension strips are ap-
plied with the object merely of keeping the Thomas’s
splint in position. No traction is necessary. If a
back splint only is used, it must reach from the tuber
ischii to the ankle . Shorter splints are worse than
useless.

Foreign Bodies, — Removal of a foreign body,
lodged within or near the joint and not visible or
palpable from the surface, should never be attempted
without X-ray localization when that is available.
Otherwise probably more harm than good will be
done by interference. If X-rays are not available,
these cases should be transferred without delay to a
unit which is provided with an installation. Of
course, in any case where the foreign body can be
seen or felt or where synovitis is already very marked,
the sooner operation is done the belter. It may be
disastrous to send the patient on another journey.

Amputation, — If the injury has implicated the
main vessels so that the foot is already cold and
dead, amputation should be done, just above the
knee, if the wound is likely to remain clean and can

WOUNDS OF JOINTS

265

be sutured, and through the knee, if sepsis is present
and the condyles undamaged. In the latter class of
cases re-amputation is frequently necessary, and,
when the condyles are left, it can be done so as to
provide the longest possible thigh stump. If, as
sometimes happens, one or other popliteal nerve is
shot away so extensively that it cannot be sutured,
and if, at the same time, the bones are much soiled
as well as comminuted, the probability is that primary
amputation is the best course. If sepsis is well
established in presence of much comminution, especi-
ally if there be gas gangrene and the patient in low
condition from haemorrhage or toxic absorption,
amputation must be done.

In considering the question of amputation, the
following points are of great importance : the

possibility of successfully removing or neutralizing
infective material, the amount and kind of com-
minution, the concomitant injury to vessels or nerves,
and the condition of the patient.

Resection. — If, in less severe cases, the opposing
ends of the long bones are so comminuted that smooth
articular surfaces are not available, it is probably
best to do primary resection.

As little bone as possible should be removed at
these primary operations— only what is soiled and
badly comminuted. At the same time free drainage
must be obtained. A patient will often bear removal
of a shattered infected condyle when a book-type
resection would kill him. Better adjustment of the
joint surfaces can be made at a later date.

Conservative Treatment of Fracture Cases, — Where

266 EARLY TREATMENT OF WAR WOUNDS

large fragments have resulted from the injury, if the
patient has been got early and is in good condition,
and if one is fairly sure of getting away infective
material, the case should be given a chance and
treated on conservative lines. Simple nailing of
bone fragments in some cases facilitates after-treat-
ment*

Removal of Patella.— As a general rule, if the
patella alone has been shattered, as happens fairly
frequently, the fragments should be removed. If
possible the synovial cavity should be closed except
for a small drainage opening. This is attained by
suturing the lateral edges and aponeuroses, possibly
after undercutting the synovial membrane on each
side, or by loosening the suprapatellar pouch as
already described. If this cannot be done a pack
should be used. The same procedure should be
carried out, if concomitant injury to other bones is
not extensive. It is wonderful how infection tends
to remain limited to the anterior part of the joint
if the limb is thoroughly immobilized — plus a flat
pad in the popliteal space.

Conservative Treatment. — When conservative
measures are decided upon, the following are the
most important operative details —

(!) Determination of the track which leads to the
depth. The knee may have been bent when the
patient was wounded, so that when the limb is
straight the track is distorted. Excision of the track
is best made when the knee is held in the same
position as when injured.

(2) Thorough disinfection of skin and track. The

WOUNDS OF JOINTS

267

whole of the skin around the knee, and for at least
six inches above and below, should be shaved and
disinfected* For final disinfection use picric acid
(3 per cent, in spirit). The external wound and track
are disinfected (a) if not very large, by the actual
cautery, or (6) by rubbing thoroughly every part
with 10 per cent, iodine or picric in spirit* The
strong solution has the effect of drying the tissues*

(3) Careful and complete excision of external wound
and track, including the edges of the wound in the
synovial membrane, if possible in one piece* Incision,
using a sharp scalpel, must be made quite clear of
the deep as well as clear of the superficial wound*
Pockets must not be cut into* Clipping infected
tissue away piecemeal courts disaster* While the
blades of the scissors arc closing, infective material
from their proximal parts is forced along to the distal.
The least little bit of infected material left behind
may prevent success.

(4) Provision of ample access to foreign bodies or
comminuted surfaces in the joint. Blind groping
with the finger is to be avoided, because the foreign
body or infective material is thus frequently pushed
beyond easy reach, and further struggles to attempt
removal pave the way for disastrous inflammation.
Extra incisions may be necessary, therefore, to give
easier access, and they must be free enough, even
to the extent of dividing the ligamentum patellae
and turning up a flap, etc*, to enable one to see the
foreign body and obtain plenty of room for manipula-
tion of instruments* If complete excision of the
infected wound has been made under proper technique,

268 EARLY TREATMENT OF WAR WOUNDS -

one should be able to get first intention after suturing,
however large the wounds may be. Results have
steadily improved, in this as in other types of war
injury, pari passu with better planned and freer
excision,

(5) Careful removal, under direct vision whenever
feasible, of all foreign material, whether free in the
joint or imbedded in the articular surfaces. If the
latter, the bone surrounding the foreign body must
be carefully chiselled or gouged away, en masse if
possible. The joint cavity is then flushed out with
5 per cent, saline, 1-1,000 flavine solution, etc. Rone
cavities may be treated sparingly with “ Ripp ” or
other paraffin paste in eases where complete eradica-
tion of sepsis is doubtful. In aseptic cases the
cavities may be filled with a fat transplant,
paraffin wax, etc.

(6) Closure of the wound in layers, using fine
catgut for the synovial membrane. Drainage tubing
should not project into the joint. Of course, if tubes
are required for the introduction of fluid, as in the
Carrel-Dakin method, they should be carried to the
deepest recesses of the joint, or inserted through a
fresh incision. They should be removed as soon as
possible*

(7) If the wound in the synovial membrane cannot
be closed, a small salt or paraffin pack, separate from
any other which may be required for the rest of the
wound, should be inserted firmly “ down to but not
into ” the hole in the synovial membrane, and should
be left until it is absolutely loose, A small tube may
be placed in the centre of the pack, reaching to the

\

vT

WOUNDS OF JOINTS

269

hole, and it may be removed in a couple of days. If
attempts are made to pull the pack away, adhesions
shutting off the main cavity of the joint are likely to
be broken down, and infection is then liable to occur,

(8) Tendinous or ligamentous structures, exposed
during operation, should be covered by skin and
subcutaneous tissue, otherwise they are very apt to
slough, and this postpones closure of the wound and
therefore prolongs convalescence.

(9) If there has been much effusion into or from the
joint, of whatever nature, or if raw surfaces, whether
of bone or soft tissue, are left in the joint at the end
of operation, a tube should always be inserted “ down
to, but not into,” the synovial cavity. Pressure of
effusion, i.e. tension, must be avoided at all costs,
because it interferes with healthy circulation in, and
absorption by, the synovial membrane, and these
are essential to successful combatting of any infection
which may have been overlooked,

(10) The injection of ether, formalin-glycerine, or
hypertonic (5 per cent.) saline solution into closed
joints, is of doubtful value. They all are irritants.
Success is claimed for all three, although their actions
are different. The common factor in tlieir application
is preliminary aspiration of the joint. This removal
of tension, along with the stimulation of the circula-
tion, is possibly the explanation of their apparently
beneficial action. The injection of or washing out
by a non-poisonous, non-irritating antiseptic like
flavine, whose antiseptic action is said to be enhanced
by mixture of the substance with body fluids, may
be of value in many cases, and has been frequently

270 EARLY TREATMENT OF WAR WOUNDS

used with no apparent detriment. The joint is
completely closed thereafter.

(11) In cases where drainage of the suprapatellar
poucli is made, vertical suspension of the limb in the
way recommended by Colonel Sir A. W. Mayo Robson
has been found of much value. The position makes
the pouch the most dependent part of the joint,
and on that account some are inclined to adopt
the method as a routine in early cases which require
drainage.

(12) The paramount importance of obtaining X-ray
skiagrams has already been indicated,

Hsemartkrosis with Small External Wound, — One
other type of injury, that which produces bsemar-
throsis in presence of small through and through
wounds, and where only slight damage to soft tissues
or bone is present, may be discussed. If the effusion
cannot be aspirated, owing to the fact that firm
clotting has occurred, best results will be obtained
by deliberately opening the joint, by free incision on
one or both sides, washing out the clot with sterile
salt or flavine solution, and stitching up again without
drainage. If the wounds are very small, one need
do no more than sterilize them superficially, unless
they come in the line of the fresh incisions, when they
should be completely excised. Such a blood-clot,
after a few days, forms excellent pabulum for the
growth of organisms, and, even though it does not
become infected, it is often the cause of much distress
and disability in later stages, owing to formation of
intra-articular adhesions. Officers at Base hospitals
in France appreciate the disastrous results of insidious

WOUNDS OF JOINTS

271

infection in such eases. Hospitals in England have
beds occupied unnecessarily long even by non-
infected cases* because, owing to the adhesions, they
require skilled massage and so forth. Arthrotomy, in
this type, must not be undertaken lightly. Technique
must be perfect, else dreadful disaster is incurred*

Retention of Cases aftei Operation.- — Operated eases
should be retained for at least twenty-four to
forty-eight hours* If the joint looks quiet and the
general condition is good, many can be evacuated
with safety at the end of that period, but in doubtful
or more serious cases evacuation should be postponed,
if possible, till all danger from sepsis has passed.
Firm compression, under a very thick layer of cotton
wool and fixation in the “ Thomas’s splint outfit, 5 ’
should be employed in the early stages. The knee
should be slightly flexed, A pad of wool in the
popliteal space, tapering to each end, tends to prevent
inflammation spreading from the back of the joint.

While the ham 55 splint of the outfit is best for
transport, and for eases in which the wounds arc in
front of the joint, yet if there is a large wound on the
posterior aspect, the thigh and leg should be suspended
on separate slings of perforated zinc, well padded
and covered with jaconet, so that access to the wound
is provided without running risk of moving the
joint.

Gentle movement, to a few degrees at first, should
be begun as soon as one is certain that the parts
are healing ascptically. If no reaction occurs, active
movements should be stimulated and increased from
day to day— very carefully in un- nailed fracture

272 EARLY TREATMENT OF WAR WOUNDS

cases. Splints may usually be left off as soon as
passive movement is begum

Sepsis. — If sepsis develops, all wounds should be
opened up freely, possibly bilateral openings should
be made, and the synovial cavity treated by inter-
mittent flushing with Dakin's, flavine, or other
suitable solution ; or else, as the Belgians have re-
commended, active movements, as free as the patients
can be tempted to make, should be encouraged.
This treatment, apparently, requires great fortitude
on the part of both patients and attendants. If
improvement does not occur within twenty-four to
forty-eight hours, a transverse or flap incision
should be made, followed by resection ; or, after free
division of the lateral and cruciate ligaments, by
packing and fixing the joint in nearly full flexion in
a specially made splint. If the articular surfaces of
the bone have been injured, the former method is
preferable. A salt or paraffin pack is preferable at
first to Carrel- Dakin’s dressings. In many cases
amputation is compulsory.

In conclusion, attention must again be directed to
the importance of rigid technique, and the necessity
for thorough and complete operation. Half measures
are worse than useless. “ All or nothing ” is a sound
watchword. If the fulfilment of these principles is
not possible, far rather fix the limbs properly and
send all patients on for treatment at the Base.

Special Remarks about Other Joints

The Question of Primary Resection*— The removal

of shattered and soiled bone may be so extensive

WOUNDS OF JOINTS

273

that a “ flail ” limb seems unavoidable, but the
success of modern orthopaedics is so great that am-
putation is unjustifiable merely on that account.

On the other hand, the provision of efficient drain-
age is essential to save life in many cases. If the
main vessels and nerves of a limb are intact, one must,
therefore, remove on the one hand as much bone as
will procure safety to the patient, and on the other
hand as little as possible to avoid a flail joint, and at
the same time provide efficient drainage. These
problems are, apparently, of least importance in the
hip and shoulder, and of most importance in the
elbow and knee. One must remember further, that
the results of late excision, for ankylosis, are more
favourable so far as useful joints are concerned than
those of early excision. It is, however, unfair to
compare the two, because of the variability in severity
of the original injury and the problems which have
therefore to be faced. At casualty clearing stations
the endeavour must always be to save life, limb, or
function, in the order named, but the limb or the
function must frequently be sacrificed in the attempt
to save the life or the limb.

Shoulder Joint — If the articular surfaces are shat-
tered, limited excision with free drainage, preferably
posterior, should be carried out. Amputation is not
often necessary. If ankylosis is likely to result from
the injury, and if the patient, for any reason, must
be kept in the casualty clearing station, the arm
should be fixed in the abducted position from the first.

In the “ position of choice,” the humerus is placed
so that its axis makes an angle of 70° with the verte-
18

274 EARLY TREATMENT OF WAR WOUNDS

brai border of the scapula, and the patient can touch
the skin over the middle of the clavicle of the oppo-
site side*

Elbow Joint —Limited excision is advisable in all
severe cases when the bones are shattered but when
movements of the hand are preserved. Those cases
in which one or other of the bones remain intact are
the most favourable. Incisions are planned according
to the position of the wounds. In many cases it is
possible to leave the epicondyles of the humerus, so
that the muscular attachments thereto are left intact.

Wrist Joint —Excision of the shattered carpal or
adjacent bones is frequently advisable. Very free
drainage must be provided. Under recent treatment
amputation is rendered less frequently necessary*
In all cases it is preferable to place the forearm and
hand in a splint, which holds the hand in slight
dorsifiexion. If ankylosis at the wrist occurs in this
position, the functions and power of the hand and
fingers are better preserved than they are in any
other.

Hip Joint.— In addition to routine wound treat-
ment, free posterior drainage, with fixation in a
suitable abduction frame, is sufficient in most cases.
Excision is frequently, and amputation only rarely,
advisable. A rapid cleansing operation may be all
that is feasible in such cases.

Ankle Joint and Tarsal Joints, — If the injury is
severe, or if the infection is not likely to yield to free
incision, resection and drainage, amputation should
be performed without hesitation. The safety, assured
by the removal of the infected limb, and the art of

WOUNDS OF JOINTS

275

the artificial* limb maker compensate, in great mea-
sure, for the loss of the foot,

REFERENCE

14 Gunshot wounds of the Kneejoint, The Conservative Operation
at a Casualty Clearing Station,** By Major R, Charles, British
Medical Journal , June 29th, 1918, page 713.

POSTSCRIPT

It has no doubt been appreciated that the methods
of treatment of varying types of wounds recom-
mended in this book are based on definite principles,
and that the greatest principle of all is that of wisely
assisting Nature in her attempts to cure. The
principles and the methods of applying them must
vary in the different stages of treatment, according
to the amount, character, and virulence of the oppo-
sition to Nature’s efforts. If a principle can be
applied with success in the treatment of all types of
wounds at the same stage, one is assured that the
principle is correct. From the basis thus established,
further progress can be made.

AUTHOR'S PUBLICATIONS ON WAR WORK IN
ADDITION TO THOSE MENTIONED IN THE
PREFACE

“Use of Mastic Varnish in Dressing Wounds,” British
Mvdical Journal , June 12th, 1915, page 1021.

“ 4 Hypertonic 3 Treatment of Wounds,” British Medical
Journal, July 3rd, 1915, page 32.

“ Treatment of Gunshot Wounds by Excision and Primary
Suture,” Journal of the Royal Army Medical Corps,
June 1915, This paper was published also in the
British Medical Journal, August 28th, 1915, page 317,

44 Treatment of Gunshot Wounds of the Knee Joint”
British Medical Journal, July 10th, 1915, page 41.

* 4 Removal of a Bullet from the Right Ventricle of the
Heart under Local Anaesthesia,” British Medical
Journal , October 16th, 1915, page 561,

44 General Treatment of Infected Gunshot Wounds*”
British Medical Journal, January 1st, 1916, page 1*

44 Gunshot Wounds of the Head,” British Medical Journal,
February 19th, 1916, page 261,

44 Early Treatment of Gunshot Injuries of the Spinal
Co rd , * ' Br itish M edica l J ourna l, J ul y 1 4t h , 1 9 1 7, page
44.

44 Early Treatment of Gunshot Wounds of the Knee
Joint,” British Medical Journal , September 1st, 1917,
page 278,

44 Use of Liquid Paraffin in the Treatment of War
Wounds,” British Medical Journal , October 20th,

1917, page 509.

44 Notes in Connection with Some Papers on Surgery of
the Chest,” British Medical Journal , November 3rd,

1918, page 580,

44 Essential Principle in the Treatment of Gas Gangrene,”
British Medical Journal , March 30th, 1918, page 369,

44 Primary Suture of War Wounds,” British Medica
Journal , April 20th, 19IS, page 467.

276

Abdominal wounds,

at casualty clearing stations,

76

complicating wounds of dia-
phragm, 225

diagnosis at advanced units,

66

examination of, 66
measures in, 66
other wounds associated with,
66

Acidosis,

anesthesia and transport in
relation to, 87

bicarbonate of soda neutralize
mg, 240

chloroform anaesthesia preci-
pitating, 144

cold influencing development
of, 84

complicating gas gangrene,
treatment, 135
how counteracted, 93
morphia in relation to, 88
sepsis in relation to, 106
tendency to, in shock hemor-
rhage, 92
Adrenalin,

use with local anaesthetics,
148, 163, 18D, 212
Advanced units, 1-4
abdominal eases at, 66
amputations and operations
at, 42

avoidance of exposure at, 23
blood transfusion at, 99, 100
care of blankets at, 15
chest cases at, 65

Advanced units ( continued ),
condition of wounded at, 10,

11

dressings at, 36-41

drug administration at, 27-9

evacuation from, 32

fluid administration at, 23-6

fractures at, 49

fractures of femur at, 57-64
fractures of humerus at, 53-6
haemorrhage at, 43-8
head cases at, 64
heating of conveyances and
dressing stations, 18, 19
hot air baths at, 21, 22
joint wounds at, 64, 260
mental condition of wounded
at, 31

multiple wounds at, 66
preventive work at, 4
protection from cold and
exposure at, 12, 23
relief of pain at, 26-7
removal of wet clothing at,
17

septic cases at, 7
shock eases at, 5, 9
splinting at, 50
stimulants at, 31
stretcher-bearing at, 11
transport from, 33
After treatment,
general observation, 171
Alcohol,

use of, during evacuation, 24
Alkalis,

diminution of r eserves in
shock haemorrhage, 88, 92

277

278

INDEX

Alkalis (continued) f

injuries requiring treatment
by, 92

in prophylaxis and treatment
of gas gangrene, 92, 172
Ambulances,

avoidance of exposure in, 23
evacuation by, 33
heating of, 19
Amputation,

anaesthetisation of skin during,

42

at advanced dressing stations,
advantages, 42, 86
dressings for, 245
for gas gangrene, 130, 131,
132

frequency following use of
tourniquets, 45
guillotine, abandoned, 127,
128

haemorrhage during control of,

43

in fractures of the femur, GO
in knee-joint injuries, indica-
tions for, 256, 2 GO, 264
indications for, 52
less frequent in upper than
lower extremity, 238
prevention of necrosis in, 245
shock in relation to, 42, 8G,
87

when unjustifiable, 273
without general anaesthetic,
42

Anaemia,

of wound surface, prevention
of, 115
Anaesthesia,

adrenalin in local, 148, 163,
180, 212

amputations without, 42
at advanced units, 7
choice of, 136, 222
dangerous with low blood
pressure, 136

excision and primary suture
under* 163

in brain wounds, 180
in chest cases, 222

Anaesthesia (oonjitiweci)*
in femur fractures, 240
in shock cases, 100, 101, 136
in spinal coed injuries, 232,
235, 236

transport of patient following,
43

Anastomosis, arterial,
in femur fractures, 244
Aneurysm,

diffuse traumatic, 46
diffuse traumatic, early treat-
ment, 48

Ankle joint injuries,
characteristics and treatment,
274 _

Anoci- association, 136
Anti-bodies,

development of, in combating
sepsis, 106

Anti -gas gangrene serum,

prophylactic and curative
qualities, 139
Antiseptics,

depot antiseptics, 109
during excision and primary
suture, 163
for raw surfaces, 247
function of, 108
in joint injuries, 267, 269
liquid paraffin as medium
for, 109

limitations in combating sep-
sis, 35, 36, 105

limitations without operation,
107, 124, 129
modem views on, 105
varieties and methods of use
at early stages, 36-40
Antitetania serum,

dosage and methods of ad-
ministration, 139
Anxiety,

factor in production of shock,
87

Arm ,

fixation of, 273
fractures of, position of patient
during evacuation and
transport, 34

INDEX

279

Arm splints,

methods of application, 51-3
Army shock centres, 102, 103
Artificial limbs,

of lower extremity more satis-
factory than those of
upper, 238
Aspiration,

of chest wounds, 226
of knee-joint, 269
Atropine,

preliminary to operations, 223

Bacterial count,

closure of wounds in relation
to, 166
Bandaging,

after application of salt pack,
115

and splinting, 59
extension, glue solution for,
248

tightening in, 248
[illustration), 249
fixation and support by, 166
haemorrhage during, 39
in femur cases, 61, 248, 253
in head cases, 65
in knee-joint cases, 260
in primary suture, 165
interference with circulation
by, 38

methods of, 38

tight, producing gangrene, 57,
62

Beverages,

in after treatment, 172
Bicarbonate of soda,

neutralising acidosis, 135, 136*
240

Bipp (Bismuth iodoform paraf-
fin paste), composition
of, 110

method of application, 36, 110
Bladder,

drainage in spinal cord in-
juries, 237
Blankets,

advantages of, 15
at regimental aid posts, 12, 15

Blankets (continued),
method of drying, 16, 17
method of folding, 13
protection by, during trans-
port, 12-15
storage of, 15

use during stretcher-bearing,
13, 14
Blistering,

mercurial dressings causing, 36
Blood,

condition in shock- haemor-
rhage, 88, 92, 93
shock following loss of, 9
Blood clot,

favouring development of gas
gangrene, 131
Blood corpuscles,
preservation of, 98
Blood count,

estimation of degree of hse-
raorrhage from, 96
Blood pressure,

decrease following hsemor-
hage, etc*, 83-87
effect of intravenous in-
fusions on, 90
how raised, 89, 134
in relation to sepsis, 106
low, anaesthesia dangerous
during, 134
Blood supply,

condition affecting the healing
of wounds, 128
factor in success of operative
measures, 107, 108
Blood test,
technique, 94
Blood transfusion, 26

at casualty clearing stations,
95, 98* 99* 100

blood test preliminary to, 94
cases most suitable for, 95
clt rated method, 94
dosage, 95

in femur fractures* 240
in shock haemorrhage mor-
tality rate, 95
success of, 93, 95
method, 94

280

INDEX

Blood transfusion {continued},
indications for, 96, 97, 134,
135

mortality after, causation,

97

post operative, 97
rest before evacuation follow-
ing, 100

sound general treatment not
to be replaced by, 100
with preserved blood, 98
Blood vessel anastomosis,
in femur fractures, 244
Body fluids,

loss of, means of compensating,
24, 25, 89

substances exerting antiseptic
action, only when in
contact with, 109
Body resistance,
to infection, 107
Bone fragments,
in the brain, 177, 184, 192
removal of, 37, 246, 272
Bones,

drainage of, 170
foreign bodies buried in, 137
long, fractures of, treatment,
238

Bony prominences,
removal of, 163, 164
Boots,

removal of, 17, 63
Boric acid,

antiseptic use, 109
Brain,

circulation of, 186
fungus of, lumbar puncture
for, 208
oedema of, 179
Brain wounds,

abscess formation, 201, 204,
205, 208

bacteriological examination
in, 187

blood sinus injury accom-
panying, 186, 206, 207
bone fragments in, 184, 1 92
bone fragments in, removal of,
202, 203, 204

Brain wounds (continued)
cause of death in, 1 90
cicatricial tissue in, causes of,
192

compression accompanying
depressed fracture, 197
compression by foreign bodies,
187

concussion following, 179, 180
depressed fracture with, 196
disastrous effects of delay in,
174, 175

drainage in, 186, 188

in presence of abscess, 169
indications for, 186
technique, 187, 188
exploration of, 204
exposure in, method of cover-
ing, 196

expression of clots and cere-
bral debris, 202
extensive and trivial, 178,
179

fatal cases of, 178
foreign bodies in, 138, 202
conditions due to, 191, 201,
204, 205
diagnosis, 184
dura injury complicated by,
200

removal of, 176-8, 192,

200, 204, 205
sepsis due to, 177
without symptoms, 205
fracture accompanying, 179
general observations, 174
haemorrhagic complications,
control of, 206, 207
hemiplegia following, 178
hernia, treatment of, 209
interference with circulation
in, 191

intracranial pressure in, in-
dications of, 185
lesions due to, and their
symptoms, 184
lumbar puncture in, condi-
tions indicating, 207, 208
penetrating, 202
points in treatment, 189

INDEX

281

Brain wounds {continued ) ,

position of patient during
transport and evacuation,
34

principles of treatment, 174
pulped area in, 183
pulped area in, removal of,
199* 202, 203

removal of sources of irrita-
. tion, 193

restoration o f function in *
175

rupture without penetration,
184

scar tissue in, 192

sepsis complicating, 176, 191

treatment,

excision and suture in, 182,
190, 192, 193, 196, 199
flaps in, 196

general measures, 194, 195
general remarks on, 212
local ansesthesia in, 180
minor operations, 182
objects of, 193
of the track, 202
opening of dura in, tech-
nique* 183, 185
prevention of haemorrhage
in, 180
success of, 194
technique, 181, 186, 190
use of catheter in, 203, 204
use of forceps in, 200
ventricular penetrations, 204
Brilliant green,

antiseptic potency, 109
tissue staining by, 154
Buccal administration of mor-
phine, 27, 28
Bullets,

causing sepsis, 136, 137
removal from tissues, 130, 137
see also Foreign Bodies
Buttock wounds,

alkalies in treatment, 92
application of salt pack to,
112

treatment, 152

see also Femur fractures

Canal barges,

evacuation by* 33
Carbohydrates, 172
Carrel’s treatment, 122
in spinal cord injuries, 236
Casualty clearing stations, 68
arrangement and equipment
of, 69, 72

arrival and reception of pa-
tients at, 72

blood transfusions at, 95,
99

chest and abdominal cases at,
76

classification of cases at, 74,
75

comfort for wounded at, 72
dressing rooms at, 73
evacuation from, 70, 74
femur cases at, 239
functions of, 70
heating and temperature of,
10, 20, 71

knee-joint cases at, 261
operation wards at, 75
operative theatres at, equip-
ment of, 76, 77
operative treatment at, general
observations, 68, 123-33,

140

position of, 70

post- operation wards at, 77,

141

pre-operative measures at,
75, 76, 140

prophylactic teatment at, 138,
139

radiography at, 140
recovery wards at, 75
removal of foreign bodies at,
136

resuscitation ward at, 75, 84,
85, 141

salt-pack treatment at, 1 L 1-20
44 shock- teams ” at, 76, 85
special and walking stations,
74

spinal cord cases at, 235
surgical teams at, 78
Catgut sutures, 165

282

INDEX

Cerebral compression,

prevention in dressing of
head wounds, 65
Cerebral concussion,
following injury, 176, ISO
Cerebral oedema, 179
Chest wounds,

closed, decision as to treat*
meat, 219

closure of, early method, 65
dangers of delay in, 65
entrance and exit, 217
foreign bodies in, removal of,
138,225

mortality from, 213
open, classification of cases,
221

dangerous nature of, 213
decision as to treatment,
219

mortality from, 220
object of treatment, 220
prevention of sepsis, 220
penetrating,

aspiration during after
treatment, 226
at casualty clearing sta-
tions, 76

blood clot in, 224
cases of closed hacmothorax,
217

causes, 221, 222
causes of death in series of
coses, 228

choice of anaesthetic, 222
collapse of lung in, 224
dangerous nature of, 214
destruction of pleura in,
223

empyema operation, 219
evacuation to the base, 226
exploration of, 223
frequency of, 214
gas infection, diagnosis, 218
liability to sepsis, 216
missiles in, 222
moribund cases, 216
operative technique, 223-5
pain of, to what due, 215
pocketing in, 224

Chest wounds

sepsis complicating, treat-
ment, 218

treatment, 215, 227, 228
sepsis complicating diagnosis,
217

sucking,

dangerous nature of, 213
decision as to treatment,
219

sepsis cause of death in, 216
treatment, 215
tangential, 221
Chloramine T,
antiseptic use, 109, 117
Chloroform anaesthesia, 136
precipitating acidosis, 144
Circulation,

cerebral, interference with,
191

condition affecting healing of
wounds, 128
interference with,
by bandages, 38
effects of, 7

predisposing to sepsis, 8
tension interfering with, 132
vigorous and healthy, non-
development of gas gan-
grene in, 131

Citrated method of blood- trans-
fusion, advantages and
success of, 94
Classification,
of wounds, 145
Clothing,

wet, removal of, 17
Cocoa,

administration to the newly
wounded, 24

Cold,

influencing development of
acidosis, 84

p rotection against, b y blankets,
12-15

shock aggravated by, 71, S3
Colloids,

action on blood pressure, 90
administration in shock hae-
morrhage, 90

INDEX

283

Conveyances,

heating of, 18
** Cooking,” apparatus,

extempore manufacture of, 2 1
Cotton woo! dressings,
careless use of, 38
Cranial injuries,
scalp closure in

( illustration) ,210,211
see also Brain ; Scalp ;
Skull
Crepitation,

late sign of gas gangrene, 9
Cmtch splint, 53
Cultures,

from wound surface, 166
Cyanosis,

increase in shock, significance
of, 97
Cystitis,

prevention in spinal cases,
235

Cytological findings, 132

Bead spaces,

treatment of, 167
Depage humerus splint, 51, 54,
56

Depot antiseptics, 109
Dextrose,

preservation of blood cells
by means of, 98
Diaphragm wounds,

excision and suture in, 226
foreign body in, 215
hernia, 216

injuries of abdominal viscera
accompanying, 225
treatment, 225
Diet,

in after treatment, 172
Digestion,

disordered, in newly wounded,
24

Disinfectants,

see Antiseptics
Drainage,

cerebral, technique, 169
efficient, necessity for, 273

Drainage ( continued ),

in application of dressings,
37

in fractures of femur, 247
in presence of foreign bodies,
167

of bladder in spinal cases, 237
of knee-joint wounds, 263
of j oint cavities, 168, 256
of pleural cavity, 226
of suprapatellar pouch, 270
of the brain, 186, 200, 201
prevention of infection by, 168
prevention of secondary hae-
morrhage in, 1 70
principles of, 167, 168
removal of tube, 170
substances used in, 167, 170,
188

Draughts,

protection from, 19
Dressing-rooms,

at casualty clearing stations,
73

table for us© in, 39
( illustrat ion ) , 3 8
Dressing stations,
see Advanced Units
Dressings,

application of, 38, 108, 146
drainage in relation to, 37
for amputation stumps, 245
for field ambulance work, 36
forms available, 35
function of, 108
haemorrhage during applica-
tion of, 39

in femur fractures, changing
of , 62, 258
in fractures, 37
in head w ounds, 64, 65
in knee-joint cases, 260
in primary suture, 164, 165
odour from, how diminished,
117

over- dressing, aggravation of
conditions due to, 41
post- operative, 121
preparation for emergencies,
40

284

INDEX

Dressings {continued) t

re-dressing, indications for,
41, 88, 109, 173
removal of, 118
salt pack, see Salt pack
sterilization of, 40
storage of, 30
substances used in, 109
warming before use, 37
Drinks,

for newly wounded, 24, 89
Drying,

of clothing, 16, 17
Dug-outs,

difficulties of work in, 1
Dura,

complicated by foreign body
and sepsis, treatment, 200
drainage of, 200, 201
excision of ragged edges,
199

exploration of, 199
exposure of, 199
foreign bodies in, 200, 201
fracture with depression, but
without laceration of,
treatment, 198

injury without foreign body
or evident sepsis, 199
opening of, 183
advantages, 185
indications for, 199
technique, 185
rupture of, 184
treatment of wounds of, 199

Elbow joint injuries,

characteristics and treatment,
273, 274
splinting in, 54
“ Electrical” energy,
in treatment, 107
Empyema,

mortality following operative
measures, 2 1 9
Encephalitis,

following brain wounds, 184
Eupad powder,
for offensive dressings, 117

Busol,

compared with salt pack, 120
evanescent antiseptic action
of, 35
Evacuation,

at casualty clearing stations,
70, 74

blood transfusion before, 109
care of cases awaiting, 23
during influence of morphia,
30

gas attack during, dangers of,
32

methods of transport in, 33
of chest cases, 226
of femur cases, 62, 63, 241, 253
of haemorrhage cases, 47
of head cases, 65, 21 2
of knee-joint cases, 271
of shock cases, time for, 32, 33,
172

of spinal cases, 235
patient's power of withstand-
i ng , 33 , 172

position of patient during, 34
rest before, cases indicating,
32, 33

shock complicating, 32, 87
Excision,

advantages of, 161
care of scalpel, 147
cases contra-indicating, 162,
163

en masse f 144, 149, 158, 164
general remarks on, 157
in spinal cord injuries, 236
late, for ankylosis, 273
necessary before suture, 159
of scalp wounds, 182, 190,
192, 199

of chest wounds, 223
of gutter wounds, 148
of knee-joint wounds, 263, 267
of lodging shell wounds, 154-6
of multiple wounds, 156
of scalp wounds, 195
of severe type of wounds,
technique, 148
of traversing shellwounds, 151,
152-4

INDEX

285

Excision (eort*mued),
of tunnel wounds, 1 51
piece- meal, failures following,
158

preparation of wounds, 162,
163

prevention of sepsis during,
157

success of, 2 56

swabbing avoided during, 150
technique, 147, 160-5
Exhaustion,

shock in relation to, 82, 88
Exit wounds,
excision of, 151
of skin and deep fascia, treat-
ment, 152, 153

preparation for application of
salt pack, 113
treatment, 143
Exposure,

of body during treatment, 19
avoidance during transport,
23

Extension,
in fractures, 50, 52
in fractures of femur, Gl, 248
in fracture of femur {illustra-
tion) f 240
splint tapes, G3

Fascia,

sloughing of, 108, 113
Femur fractures,

amputation in, GO, 245
amputation in, indications for,
243, 244

anaesthetics in, 24D
antiseptics in, 247
bandaging in, 38, 61, 248
blood transfusion in, 240
cases at casualty clearing sta-
tions, 74, 75, 230, 241
comminuted, 259
drainage in, 247
dressings in, changing of, G2
frequency of, 239
gas gangrene complicating,
244

Femur fractures {continued) t
general observations on, 238
haemorrhage complicating,
treatment, 240* 241
mortality of cases at casualty
clearing stations, 59
prevention of sagging of soft
parts in, 166, 167
removal of bone fragments,
246

removal of the boot in, 63
shock in,

blood transfusion for, 95
frequency of, 59
prevention of, 58, 241
splinting in, methods and
varieties, 49, 57-63, 248-
59

splinting minimizing ten-
dency to shock, 85
transport and evacuation of
cases of, 6, 34, 62, 63, 241,
253

treatment,

apparatus for raising leg
(illustration) , 242
consorv ative, 245-7
dangers of delay in, 241
extension in, Gl-3
first steps in, 239, 241, 243
general considerations, 240
immediate primary suture,
24 G

immobilization in, 247
technique, 243, 246
without removal of splint,
242, 243
Fibrous tissues,

healing capacity of, 108
replacing muscular tissue in
gunshot injuries, 113
sloughing of, 121
Field ambulances,
sec Advanced Units
Field medical cards,
notes on, 66
Fingers,

tight, extension in arm splint-
ing producing gangrene
of, 57

/

f

286

INDEX

Fixation,

and support, by bandaging
and splints, 166
Flavins,

antiseptic potency, 109, 269
in knee-joint injuries, 268
treatment by, 268, 269, 270
Fluid administration, 23
in haemorrhage, 83
in shock, 89
intravenous method, 89
vomiting complicating, 89
Fluids,

body loss of, from haemor-
rhage, 88

forming media for growth of
micro-organisms, 167

Foot,

gangrene produced by tight
extension, 62
method of supporting, 251
prevention of rotation, 58, 61,
63

Foot piece, 58, 61, 251
Foreign bodies,
deflection of, 154
degree of sepsis in relation to,
136

drainage in presence of, 167
examination for, 154
in chest wounds, 215, 222, 225
in the brain, 184 , 187

removal of, 1 76, 204, 205
with sepsis, 200
in the knee joint, 257, 264, 268
non- removal of, indications
for, 137
removal of, 136

indications for, 136, 138
time for, 137
sepsis due to, 141, 167
Fractures,

amputation less frequent in
upper than in lower ex-
tremity, 238

blood transfusion for shock
hemorrhage in, 95
compound,

development of shock in,
85

Fractures {continued),
dressing in, 37, 115
preparation of the wound,
113

early removal of bone frag-
ments, 37

early amputations for, indica-
tions and contra-indica-
tions, 51, 52

excision in treatment of, 157
extension in, 50, 52
operations in the field, 42
prevention of rotatory move-
ments, 50

prevention of sagging of soft
parts in, 167
rest for limb in, 116
splinting in, general remarks
on, 49, 50, 86

8M also under names of
Bones, Joints, etc.
Function,

impairment of, 160
restoration after primary su-
ture, 160
Fungus cerebri,

lumbar puncture for, 208
Furrow wounds,

treatment by excision and
primary suture, 161

Gangrene,

tight bandaging producing,
57, 62
Gas gangrene,

acidosis complicating, treat-
ment, 135

amputation for, 130, 131, 132
avoidance of recurrence of,
130, 131

bicarbonate of soda adminis*
tration in, 13 5, 136
common association of shock
haemorrhage with, 92
complicating femur fractures,
244

conditions favouring develop-
ment of, 130, 131
development of , 126, 129

INDEX

287

Gas gangrene (continued),

diminution of alkaline re-
serves in, 92
early recognition of, 8
euphemia occurring with, 97
evacuation during, dangers of
32

following salt-pack treatment,

119

non- development in presence
of vigorous circulation,

131

operative treatment to be
immediate, 144
parts specially liable to be
affected by, 8

prognostic value of pulse rate
in, 97

prophylaxis, by alkalis, 172
rapid development of, 7, 141
serum prophylaxis, 139
shock- dev eloping, alkaline
treatment, 92
early symptoms, 9
Gauze pack, 114
removal of, 109
Glucose,

in saline administrations, 25
Glue solution,

for extension bandages, for-
mula, 248
Glycerine dressing,
following use of salt pack,

120

Gooch splinting, 54, 57, 250, 260
Gum,

administration in shock,
haemorrhage, 26, 90 , 91,
99, 135

Gutter wounds, 146
excision of, 148

Haemarthrosis,
treatment, 270
Hemolytic streptococci,
presence contra-indicating su-
ture, 166
Haemorrhage,

application of tourniquet in,
method, 48

Hemorrhage (continued),

blood volume decreased in, 83
blood transfusion in, 94, 95
care of cases during transport,
26

complicating fractures of fe-
mur, 240, 241
control of , in the field, 44
splinting following, 47
danger of death from, 44
difficulties in estimating
amount of, 82

diminution of alkaline reserves
in, 92

during application of bandages
and dressings, 39
evacuation of cases of, 47
favouring development of
sepsis, 8

fluid administration in, 83, 89.
90

from early amputations, con-
trol of, 43

from chest wounds, relief of, 65
from intracranial sinuses, con-
trol of, 206, 207
gum-saline administration in,
advantages, 91

inflammatory swellings due
to, 132

i n t racerebral , accompany in g
skull fractures, 183
intravenous gum solution for,
26

operations for, 44, 45
packing in treatment of, 46, 47
pleural, 218

predisposing to shock, 9
prevention during drainage,
170

prevention during excision
and primary suture, 163
prevention during operative
treatment, 145
prognosis in, 96, 97
pulse rate in relation to, 96
severe, sepsis following, 44
severity of, how estimated, 96
shock in relation to, 82, 88
thirst following, 23

/

288

INDEX

Hsc most asia, 157
Haemo thorax, aseptic, 2 IS
aspiration in, 218
** closed/* cases of, 217
diagnosis, 217

haemorrhage complicating,
218

in chest wounds, dangerous
nature of, 216
operative measures, 218
removal of cases to be de-
layed, 218

respiratory distress due to,
215, 216
treatment, 217
Ham splint,

application of, 58, 250, 271
Hand,

bandaging producing gam
grene of, 57
dorsiflexion of, 274
Head wounds,

dressing and bandaging in,
64, 65

excision in, advantage of
161

transport and evacuation of,
34, 65

treatment of, 64, 174

see also Brain, Skull, etc.
Healing,

by first intention, 159, 161
delay in, 160

following excision and suture,
158, 159, 161

Heart,

foreign body in, 215, 222
Heat,

artificial methods of supplying,
18,19

see also Warmth
Heating,

of conveyances, 18
of dressing stations, 1 9, 20
Heel clips,

in leg splinting, 58
Hoiby 4 s box for storing dressings,
39

Hernia cerebri,
treatment, 209

Hip joint injuries,

characteristics and treatment,
273, 274

with femur fracture, 245
Hot air,

devices for using, 20, 21, 22
Hot w T ater bottles,
early use of, 1 7
Humerus,

in “ position of choice/* 273
injuries to, 273, 274
Humerus fractures,

splinting in, methods, 53, 55
splints applied for (illustra-
tion) , 54, 56

tight bandaging producing
gangrene of fingers and
hand, 57

transport of cases, 55
Humerus splints,
application of, 51
{ illustrations ), 51

Infection,

see Sepsis
Infective material,

removal before suture, 159
Inflammatory swellings,

bleeding or infection causing,
132

operation desirable before on-
set of, 124

use of salt pack in, 110
virulent nature of, in present
war, 123
Insomnia,

shock in relation to, 87
Intrapleural hemorrhage, 05
Intravenous infusion,
of gum solution, 26
Intravenous saline injection,
in shock, 89, 90
influence on blood pressure,
90

transitory action of, 90
Iodine,

disinfection of raw surfaces by,
149, 163

disinfection of skin by, 35

Iodoform,

antiseptic action, on what
dependent, 36* 109
see also Bipp

iodoform-paraffin, 36, 109

Joint wounds,

active movements after opera-
tions, 169

amount of bone to be removed,
273

drainage of, 168, 236, 273
fixation essential during trans-
port, 169

foreign bodies in, removal of,
138

general observations on, 234
improvements in treatment,
254

penetrating wounds, splint-
ing in, 64

question of amputation, 272,
273

special remarks about, 272
sterilization of, 270
washing out of cavities, 269
see also under names of par-
ticular joints, e t g. Knee-
joint, etc*

Jones’s extension humerus splint,
application of, 54

Knee,

flexion in treatment of thigh
fractures, 61
Knee-joint wounds,
bad effect of transport on, 255
cases for retention at casualty
clearing stations, 262
eases for transfer to base, 261
comminuted fractures, 259
evacuation of cases, 271
factors of importance in, 273
femur fractures with, 245
fixation during transport, 264
haemarthrosis, 270
improvements in treatment,
254-6

Knee-joint wounds {continued),
inflammatory disintegration
following, 255

open typo, characteristics, 258
retained missiles in, 257, 258,
264, 268

sepsis complicating, 272
serious nature of , 255
steady oozing from, 47
types of, 256
treatment,
after operation, 271
amputation, indications for,
256, 260, 264
antiseptics in, 267
aspiration in, 269
at casualty clearing sta-
tions, etc,, 260, 261
conservative, technique,
265-70

drainage and packing in,
168, 263, 270

dressings and bandaging in,
260

early, importance of, 255
early, teclmique, 260
excision in, 263, 267
first steps in, 262
general remarks, 262
movements following, 271
object of, 263
of hacmarthrosis, 270
of sepsis, 272

removal of foreign bodies,
264, 268

removal of patella, 266
resection, 265

retention of cases after,
271

splinting in, 64, 260
suture in, 263, 268
Knee splints,
observations on, 50

Lacerated wounds,

best results obtained by opera-
tion, 129

Tapid development of sepsis
in, 142

,„ r :

INDEX

290

INDEX

Laminectomy,

rarely indicated, 236
technical difficulties of, 231
Leg,

raised from operating table,
apparatus for, 242
Leg bones,

fractures of, splinting in, 64
see also Femur ; ' Knee, etc.
Leg splints,

varieties and methods of
application, 57“63
Ligatures,

in treatment of early haemor-
rhage, 46

Liston's long splint,

in fractures of femur, 59
Li v er,

foreign bodies In, 138
Local anaesthesia,
in chest cases, 222
in excision of wounds, 148, 163
in head injuries, 180
in spinal injuries, 235
in “scissors” amputation, 42
Lodging wounds, 146
examination of, 354, 155
gravity of, 125
Lotions,

choice of, 35

to be warmed before use, 37
Lumbar puncture,

amount of fluid withdrawn,
208

cases necessitating, 207, 208
indications for, 199, 202, 209
when not to he made, 209
Limg,

collapsed, in chest wounds,
224

foreign body in, 215
gangrene and laceration of,
224

Lymphagogic effect,

of salt pack, 110

Magnet,

extraeton of foreign bodies
from brain by, 201, 205

Massage, 173

Mas t iso 1 varnish dressing, use
of, 150, 164, 165, 212
Medical cards,
notes on, 66
Meningitis,

accompanying fungus cerebri,
208

following brain wounds, 184
Mental condition,

influencing development of
shock, 82, 87, 135
of the wounded, 31, 70
Mercurial dressings,

blistering caused by, 36
Metabolism,

changes due to morphia, 6,
29

disturbed, complicating treat-
ment of shock, 135
Methylene blue,

tissue staining by, 154
Missiles,

character and size of, 143
in wounds,

see Foreign bodies
velocity of, degree of injury
in proportion to, 125, 126
Morphia,

acidosis in relation to, 88
administration of, 30
errors in, 29

indications and contra-indi-
cations, 88
methods, 27

and omnopon, action com-
pared, 7, 172
beneficial effects of, 29
conditions contra-indicating,
30, 31, 88

depressing effect of, 6
disadvantages of, 29
dosage, 30

evacuation of patient under
influence of, 30
in treatment of shock, general
considerations, 88
injections, advantages of, 28
preliminary to operations, 102,
223

INDEX

291

Morphia {continued),
relief of pain by, 30
tabloid administration by
mouth condemned, 27
use of, 172
Motor ambulances,
employment in evacuation, 33
heating of, 19

inflation of tyres in relation
to degree of j olting, 34
Multiple wounds,

associated with severe shock,

06

characteristics, 156
exposure of body during treat-
ment, 19

immediate operative treat-
ment, 133

treatment of, technique, 156-7
Muscles,

bacteria embedded in, not
dislodged by antiseptics
alone, 105

condition in gunshot wounds,
113

destructon of, liable to sepsis,
8, 148

foreign bodies embedded in,
137

healing capacity of, 108
infection of, 113
lacerated, favouring growth of
gas gangrene bacilli, 130

Narcotics,

administration of, 28, 30, 31
Natural faculties,

condition during shock, 31
Neck,

penetrating wounds of, pro-
fuse hemorrhage from, 46
Nervous equilibrium,

loss of, complicating treat’
ment of shock, 135
Nitrous oxide and oxygen
anaesthesia,
in chest eases, 222
in femur fractures, 240
in treatment of shock- haemor-
rhage, 101

Nourishment,

administration of, to newly
wounded, 23

(Edema,

increase of, during salt-pack
treatment, 119
Omnopon,

action and effects of, 31
and morphia, action compared*
172

in relief of pain, 7
prior to operations, 223
us© of, 172
Operating theatres,

at casualty clearing stations,
equipment of, 76, 77
pre* and post-operation wards,
at casualty clearing sta-
tions, 74, 75
Operations,

adequate, importance of, 107
after treatment, general, 171
at aid posts and casualty
clearing stations, etc.,
1, 42, 108

before evacuation, 35
blood supply a factor in success
of, 107, 108

inadequate, not made good by
antiseptics, 107
in p re-inflammatory stage,
158

prevention of haemorrhage in,
145

sterilization of skin for, 146
time for, how determined,
143, 144
Optic neuritis,

complicating depressed skull
fracture, 197

Packing,

see Salt pack, Dressings
Pain,

factor in production of shock,
87

pericardial, 215
relief of, 6, 26,27, 29, 30

292

INDEX

Pain [continued),

shock in relation to, 27, 87
sudden onset in salt pack
treatment, significance,
119

Paraffin,

in prevention of sepsis, 107
medium for antiseptics, 109
Paraffin dressings, 109
action and effects of, 110
advantages of, 36
drainage with, 108
storage of, 30
use of, 30
see also Ripp, I.P.
Paraplegia,

spinal cases showing, 233
Parietes,

tangential wounds of, 214
Patella,

drainage of, 270
removal of, technique, 200
Patella fractures,
characteristics, 259
excision and suture in, 263
treatment, £59
Pericardial pain,

in chest wounds, 215
Picric acid,

disinfection of skin by, 35, 140
disinfection of raw surfaces
by, 149

in treatment of fungus cerebri,
208

in early treatment of head
wounds, 04

use during excision and pri-
mary suture, 163
Plastic operations,
of the scalp, 210, 211
Pleura,

destruction in chest wounds,
223 *

Pleural cavity,
aspiration of, 226
cleaning of, in chest wounds,
224, 225
closure of, 220
exploration of, 224
injuries and wounds of, 214

Pleural cavity (conifttwcd),
inspection of, 223
pro lapse into, 225
wounds of, treatment, 65
see also Chest wounds
Pocketing,

presence of , 103, 164
in chest wounds, 224
Potassium permangate,
for offensive dressings, 117
Preventive work,

difficulties and importance
of, 4, 5
Projectiles,

velocity of, degree of injury
in proportion to, 125, 120
Proteids, 172
Psychic shock, 31
Psychology,

of the wounded, 31
Pulsating vessels,

foreign bodies in neighbour-
hood of, 137
Pulse rate,

in gas gangrene, significance
of, 97

in relation to haemorrhage, 96
in relation to shock, 97
indicating dangers during eva-
cuation, 32

indicating progress of salt
pack treatment, 119

Railways, light,

evacuation of wounded by,
33

Reading bacillus,

application of culture of, 121
infection by, 129
Reception rooms,

at casualty clearing stations,
73

Recovery wards,

at casualty clearing stations,
75

Rectal salines,

advantages and disadvantages
of, 25

in treatment of shock, 89

INDEX

293

Regimental aid posts*
treatment at,

see Advanced Units*
Respiratory distress,

due to chest wounds* 215,
216

Rest,

for the wounded, 72
sedatives for, 171
Resuscitation,

ordinary means of, 134
Resuscitation ward,

at casualty clearing stations,
75, 84, 141

Ribs,

fragment penetrating chest,
215

involved in chest wounds, 223
resection of, 224
Rotation,

prevention in fractures of ,
femur, 63, 251

Sagging,

of soft parts, prevention of,
166

Salines,

administration in shock he-
morrhage, 25, 8£M)0, 91
rectal and subcutaneous ad-
ministration, technique,
25, 26

Salt pack treatment, 1 1 1
action and effects of, 1 10
advantages and success of,
111 , 112 , 120 , 122
application of culture of Read-
ing bacillus in, 121
care of arteries during, 115
cases in which of great value,
120

decomposition of dressings
during, 117

glycerine dressing following,
120

indications for changing, 119
normal favourite course, 117
of amputation stumps, 245
of fractures of femur, 247

Salt pack treatment {continued),
of knee-joint wounds, 268, 272
preparation of wound for
112, 113, 162, 103
pulse rate during, 116, 117
relief of pain during, 116
redressing in, 118
temperature during, 116, 117
Sanitas powder,
for offensive dressings, 117
Scalding,

prevention of, 18
Scalp wounds,
closure of, 209

{illustration), 210, 211
elliptical loss of tissue in,
211

enlargement for procuring ade-
quate access, 199
excision and suture of, 182,
196, 197, 200, 207, 211
septic, 177

treatment of, 64, 195
see also Brain, Skull
Scalpels,

for excision, 147
Scapula wounds,

continuous steady oozing
from, 47
Scar tissue,
cerebral, 192
Sciatic nerve,

destruction in fractures of
femur, 244
Scopolamine,
action and effects of, 31
Sedatives,

use of, 7, 171, 172
Self-inflicted wounds,

accompanied by shock, 82
Sepsis,

acidosis in relation to, 106
all wounds to be regarded as
infectod, 128

antib od y dev el opulent i n co m -
bating, 106

antiseptics in prevention of,
limitations, 35, 36, 105
bicarbonate of soda adminis-
tration for, 240

294

INDEX

Sepsis [continued),
blood pressure in relation to,
106

body resistance to, 108
bullets and shell fragments
causing, 136, 137
cause of mortality following
transfusion, 97
causing death in shock, 100
complicating brain wounds,
176 200

complicating chest wounds,
216, 217

complicate g knee-joint

wounds, 272

conditions favouring develop-
ment of, 8

degree of, indicated by foreign
bodies, 141, 143
essentials in combating, 108
favourable media for growth
of, 167

following drainage, 1 70
foreign bodies in relation to,
136, 167

improvements in treatment of,
128

in apparently clean wounds
125

inflammatory swellings due
to, 132

kind of wounds attacked by, 8
less virulent in upper than in
lower extremity, 238
methods of dressing favouring
development of, 37
old methods of treatment, 127
operative treatment before
development of, 124, 144,
158, 159

prevention of, 7, 107, 157, 163
rapid development of, on what
dependent, 141
salt pack in prevention of, see
salt pack, 1 17

syringing in cases of, doubtful
value of, 36

transport aggravating, 159
virulent nature of, in present
war, 123

Septicemia,

acute, rapid development of,

141

Serum,

anti- gas gangrene, administra-
tion of, 139

anti- tetanic , administration of,
138

development of anti bodies,
aided by injections, 106
Shell shock,

mental condition of patient,
31

sm also Shock
Shell wounds,

characteristics and degree of
infection, 143

condition before treatment,
126

dangerous nature of, 1 45
lodging, treatment, 154, 155
of the brain, 177, 178
of knee joint, 258
open, of the chest, 221 , 222
removal of fragments from
tissues, 137

sepsis complicating, 137
traversing, treatment, 152,
153

Shock,

aggravation and production
by over- dressing, 41
amputation in relation to, 86,
87

and sepsis following severe
haemorrhage, 44
application of warmth during,
17-22

association of gas gangrene
with, 92

bicarbonate of soda neutral-
izing acidosis in, £40
blood loss to bo madeg ood
in successful treatment,
134

blood pressure indicating safe-
ty or danger of operative
measures, 96

blood transfusion in, indica-
tions for, 96, 97

&hock {bontinued),
blood transfusion in,
method, 94
mortality rate, 95, 97
sound general treatment not
to be replaced by, 100
success of, 93, 95
with preserved blood, 98
Careless handling of patient
producing, 11, 27, 88
cause of death in, 100
causes of, 6, 10, II, 27, 41, 71,
83, 88

cold maintaining or aggra-
vating, 71, 83
compound fractures and, 85
conditions complicating, 81
dangers of transport during,
172, 173

development during transport

5 - 6 , 10

diminution of alkaline re-
serves in, 02

disturbed metabolism com-
plicating treatment, 135
emotional and sensory stimuli
provoking, 32

evacuation of patient during,
32, 87, 172

exhaustion subsequent to in-
jury causing, 82
factors in production of, 86,
87

favouring development of sep-

sis, 8

fluid administration in, me-
thods, 89

haemorrhage in relation to, 82
haemorrhage predisposing to,
9

hot-air bath increasing aci-
dosis in, 93

in chest wounds, dangerous
nature of, 216

increase of cyanosis in, sig-
nificance of, 97
individual capacity to with-
stand, 82

infusion of colloids in, 90
in slightly wounded, 9

Shock {mntinutid))

mental condition of patient
during, 31, 82

morphine administration in,
27-31

multiple wounds associated
with, 66

natural faculties of patient
during, 31
nature of, 80, 81
pain in relation to, 27
prevention during amputa-
tions, 42

prevention in fractures of
femur, 58, 59
prognosis in, 96, 97
psychic, 31

pulse rate in relation to, 97
replenishing of exhausted re 1
serves in, 88 -

resuscitation in. 96, 97
self-inflicted wounds accom-
panied by, 82

splinting minimizing produc-
tion of, 50, 85
stimulants in, 3 1
transport causing, 6, 10
vomiting complicating fluid
administration, 89
warmth essential in manage*
ment of, 84

operative treatment, 100
advances in, 69
anesthetics in, 100, 101,

136

at casualty clearing sta-
tions, 76

delayed* dangers of, 133
delayed, indications for, 135
immediate, 132
morphia in, 88
not well bom© by old-
standing cases, 133
observations on, 80, 102
patients power to with-
stand, 100, 101

prematureand delayed, dan-
gers of, 133
salines in, 25
technique, 101, 102

296

INDEX

Shock ( continued ) f

primary, on the field, 5-7
nature of, 81
secondary, nature of, 81
factors influencing develop-
ment of, 81
Shock haemorrhage,

factors in treatment, 88
intravenous fluid administra-
tion not recommended in,
90

loss of body fluids and alkalis
following, 88

operative treatment, cause of
success of 1 34
see also Shock, above
Shock centres,

establishment and functions
of, 102, 103
Shock teams,

at casualty clearing stations,
70, 85

She ulder j oin t i nj uries ,
characteristics and treatment,
273

fractures involving, applica-
tion of splints, 53
Shrapnel,

excision of wounds due to,

151

removal from tissues* 136, 137
sepsis due to, 136, 137
Skin,

ansesthet i cation of, 42
disinfection of, 35, 14G, 149,
163

extensive destruction of, 145
gangrene produced by tight
bandaging, 02

slight destruction with exten-
sive damage to deeper
parts, 146

treatment of wounds of, 152-3
Skull- cutting forceps,
use of, 198, 200
Skull wounds,
closure of, 209

* depressed fracture of inner
and outer tables, 197
exploration for, 196

Skull wounds (continued ) ,
depressed fractures (coitk),
without definite external
signs of, 197

without laceration of the
dura, treatment, 198
treatment, 197, 199
fractures, 183, 189

blood sinus injury accom-
panying, 206, 207
removal of bone area, 206
without depression, 197
general remarks on operation,
212

injury to dura without foreign
body or evident sepsis,
199

preparation for excision, 196
principles of treatment, 174,
1 94, 195

see also Brain, Scalp
Slings,

for extension splinting, 249,
251

support by, 167
Sloughing,

drainage tubes causing, 1 70
in infected wounds, 308, 113
loosening of, to what due,
120

Sodium bicarbonate,
methods of administration,
25, 26

Sodium chloride pack
see Salt pack
Soft parts,

operative treatment of wounds
of, 147-56

prevention of sagging of, 166
salt pack treatment of wounds
of, 117-18
Sole clip,

leg extension by means of , 63
Sphagnum moss pads, 38, 121
Sphygmomanometer,
indicating necessity for trans-
fusion, 96
Spinal anaesthesia,
in femur fractures, 240
in shock-hemorrhage, 101

VI

INDEX

Spinal cord injuries,
bone pressure on cord, 234
Carrel* s after treatment in,
236

condition of the patient, 231
decision as to operation, 232,
233

drainage of bladder in, 237
evacuation without delay,
indications for, 23d
fractured laminae, 232
general observations on, 230
local anaesthesia in, 232, 235
local concussion, 233
operative treatment, 230
difficulties in, 231
immediate, indications for,
230, 234

laminectomy, 236
selection of cases for, 235
technique, 235—6
paraplegia, causes, 233
partial division of cord, 234
prognosis, 230, 231
pulping of cord, 233, 234
Splinting,

during application of salt pack,
116

during stretcher bearing, 11
during transport, 50
easy readjustment of, 50
extempore, 55
extension, tapes for, 63
fixation and support by, 166
following control of haemor-
rhage, 47

general remarks on, 50
in cases of diffuse traumatic
aneurysm, 48

in fractures, necessity for, 49,

85

in fractures of femur, tech-
nique, 2 4 8“ 50
{ illustration) 7 252
in fractures of humerus, 51-5
in knee-joint cases, 260, 264,
271

in leg cases, 04

limiting dangers of transport,

86

297

Splinting (continued),
slings for, 249, 251
stretcher bearers* use of, 11
Staining,

of dead and dying tissue, 144
Steam,

sterilization of dressings by
extemporized method, 40
Stimulants,

in treatment of shock, 31
Stretcher bearing,

application of warmth during,
12, 18

avoidance of exposure during,
23

care of patient during, 11, 33
of femur cases, 62, 63, 251
use of blankets during, 12-15
work of, 11

S ub cutaneous i nj ectiono f salines,
technique, 25, 26
Support,

by bandaging and splints, 166
Surgical teams,

at casualty clearing stations,
78, 133

Suspension bars,
in femur cases, 251
in transport, 58, 62
Suture*

foreign bodies to be removed
prior to, 140

general remarks on, 157-9
hemolytic streptococci con-
tra-indicating, 166
observations on, 150
of brain wounds, 182, 193
of chest wounds, 65
of diaphragm, 226
of knee-joint wounds, 263,
268

of scalp wounds, 207
technique, 209, 211
of spinal cord injuries, 236
primary,

advantages of, 160, 1 61
antiseptic measures pro-
iiminary to, 150
cases suitable for, 160
delayed, 165

/

29S

INDEX

Suture {continued) Y
primary

experience necessary for, 23ft
healing following, 158
in lodging shell wounds, 155
indications lor, 110
of fractures of femur, 245,
246

removal of infected material
before, 15ft
technique, 160-66
tension in relation to, 162
results in series of cases, 15ft
salt pack preparation for,
112

secondary, cases suitable for,
166

technique, 150, 164-6
Synovial cavities,
drainage of, 168, 169

Table,

for use in dressing-rooms, 37,
3ft

Tapson’s sole clip,

leg extension by means of, 63
(illustration)' 56
Tarsal joint injuries,

characteristics and treatment,
274

Tendinous structures,
sloughing of, 108, 113
Tension,

amount affecting wound edges,
how estimated, 162
complicating treatment, 171
interfering with circulation,
132

relief of, 171
Tetanus,

development of symptoms of,
13ft

prophylaxis, 138, 13ft
Thigh splints,

application of, 58-63, 250
Thigh wounds,

alkalis in treatment, 92
splinting in, 50

Ace also Femur fractures

Thirst,

relief of, in newly wounded, 23,
83, 8ft

Thomas’s splint in fractures
of the arm (illustration),
53, 54, 56

in fractures of femur, 4ft, 57-ft,
247

(illustration) f 252
in knee-joint injuries, 260, 264
reduction in cases of shock
due to, 85
Thorax,

see Chest
Tibia,

comminuted fracture of, 25ft
Tins,

adaptations as steam steri-
lisers, 40

Tissue staining, 154
Tissues,

anomalies in healing power of,
107, 108

bacteria not dislodged by anti-
septics alone, 106
destructive power of projec-
tiles on, 125, 126
extensive destruction of, 145,
146

foreign bodies in, examination
for and removal of, 154,
155

lascerations by high explo-
sive shells, 124

necrosis during salt pack
application, 115
resistance to sepsis, how aided,
106

Tourniquet,

application of, method and
uses, 43, 48, 4ft
frequency of amputations fol-
lowing use of, 45
pneumatic, use during opera-
tions, 145
use in excision, 14ft
Transfusion,

see Blood transfusion
Transport,

acidosis in relation to, 87

INDEX

299

Transport (emtinued),

aggravating infection, 159
application of warmth during,
devices, IS

avoidance of exposure during,
23

avoidance of shock during, 5-7,

10

had effects on shock, 6, 172,
173

care of patient during, 6
essentials in, 50
fixation of j ointa essential
during, 169

heating of conveyances during,
16

of femur cases, 62, 63, 251
(illustration), 252
of haemorrhage eases, 26
of head cases, 65
of humerus cases, 55
of knee-joint cases, 255, 264,
271

position of patient during, 34
sedatives during, 6, 7
splinting during, advantages
of, 50, 86

suspension bars in, 58, 62
Traversing wounds, 146

excision of , technique, 152-4
with explosive exit, excision
of, 151
Trephining,
technique, 198
Tunnel wounds,
excision of, 151

TJrotropine,

administration in brain
wounds, 195

Urotropine (continued) y

prevention of cystitis by, in
spinal cases, 235

Varnish dressing,
use and advantages of, 150,
164, 165, 212

Vomiting,

prevention and treatment of,
24, 25

Warmth,

at advanced dressing stations,
18

devices for providing, 18, 20,
21, 22, 84

during stretcher bearing, 12,

18

essential in management of
shock, 84

necessary for the wounded,
71, 77

Wet clothing,
removal of, 17

Wool,

careless use of, 68

Worry,

factor in production of shock,
87

Wrist joint injuries,

characteristics and treatment,
274

X-rays,

advantages and value of, 140
apparatus necessary in casual
ty clearing stations, 140

Zinc gutters and slings, 167

—

Date Due